Provider Demographics
NPI:1174594253
Name:SU, HENRY H (DO)
Entity type:Individual
Prefix:DR
First Name:HENRY
Middle Name:H
Last Name:SU
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412-22 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-2908
Mailing Address - Country:US
Mailing Address - Phone:215-684-5344
Mailing Address - Fax:215-232-4093
Practice Address - Street 1:841 E HUNTING PARK AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-4800
Practice Address - Country:US
Practice Address - Phone:215-537-7695
Practice Address - Fax:215-537-7001
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS009559L207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017734940005Medicaid
PA051216Medicare ID - Type Unspecified
PA0017734940005Medicaid