Provider Demographics
NPI:1295739688
Name:ANDERSON, SUSAN M (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:1210 MEDICAL ARTS BLVD
Mailing Address - Street 2:STE 102
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46011-3437
Mailing Address - Country:US
Mailing Address - Phone:765-298-4111
Mailing Address - Fax:765-298-4994
Practice Address - Street 1:1210 MEDICAL ARTS BLVD
Practice Address - Street 2:STE 102
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46011-3437
Practice Address - Country:US
Practice Address - Phone:765-298-4111
Practice Address - Fax:765-298-4994
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
IN010277212084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
E05600Medicare UPIN
AN507130Medicare ID - Type Unspecified