Provider Demographics
NPI:1093821621
Name:SALTER, MARY SUSANNA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:SUSANNA
Last Name:SALTER
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:PO BOX 1155
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56619-1155
Mailing Address - Country:US
Mailing Address - Phone:218-766-9281
Mailing Address - Fax:
Practice Address - Street 1:514 BELTRAMI AVE NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-3010
Practice Address - Country:US
Practice Address - Phone:218-766-9281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN36411207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN57G72SAOtherBCBS
MN8HZD45Medicare ID - Type UnspecifiedMEDICARE
MNF85463Medicare UPIN