Provider Demographics
NPI:1063548642
Name:BRANNON, SUSAN A (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:BRANNON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8160 SEATON PL
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-7204
Mailing Address - Country:US
Mailing Address - Phone:334-272-1799
Mailing Address - Fax:334-272-4876
Practice Address - Street 1:8160 SEATON PL
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-7204
Practice Address - Country:US
Practice Address - Phone:334-272-1799
Practice Address - Fax:334-272-4876
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL14224261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL631214880OtherTAX ID
AL000088077Medicaid
AL051088077OtherBCBS PROVIDER ID
AL000088077Medicaid