Provider Demographics
NPI:1083648109
Name:RIVERS-PAYNE, SUSAN (MSN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:RIVERS-PAYNE
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 HOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45220-1905
Mailing Address - Country:US
Mailing Address - Phone:513-861-3001
Mailing Address - Fax:513-559-2020
Practice Address - Street 1:1501 MADISON RD FL 3
Practice Address - Street 2:
Practice Address - City:WALNUT HILLS
Practice Address - State:OH
Practice Address - Zip Code:45206-1780
Practice Address - Country:US
Practice Address - Phone:513-354-5238
Practice Address - Fax:513-354-5237
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN084379NP05398363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2153771Medicaid
KY7801148OtherMEDICAID
S94257Medicare UPIN
OH2153771Medicaid