Provider Demographics
NPI:1548295587
Name:GOHEEN, SUSANNA M (MD)
Entity type:Individual
Prefix:
First Name:SUSANNA
Middle Name:M
Last Name:GOHEEN
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 1:22911 JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:SMITHSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21783-1617
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22911 JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:SMITHSBURG
Practice Address - State:MD
Practice Address - Zip Code:21783-1617
Practice Address - Country:US
Practice Address - Phone:301-824-3343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD435405207R00000X, 208000000X, 207R00000X, 208000000X
MDD71052208000000X, 207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD420056000Medicaid
P00280917Medicare PIN
VAP002890917Medicare PIN
CACG854ZMedicare PIN
VAMC12516Medicare PIN
MD187573ZABGMedicare PIN
VAI39285Medicare UPIN