Provider Demographics
NPI:1154301091
Name:KELLOGG, SUSAN E (PA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:KELLOGG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:G
Other - Last Name:BAUMWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:630 PLANTATION ST FL 12
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2038
Mailing Address - Country:US
Mailing Address - Phone:508-871-0700
Mailing Address - Fax:508-616-4411
Practice Address - Street 1:900 UNION ST
Practice Address - Street 2:
Practice Address - City:WESTBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01581-5408
Practice Address - Country:US
Practice Address - Phone:508-871-0700
Practice Address - Fax:508-616-4411
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA275363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AP0289OtherMEDICARE B
970013334OtherRAILROAD MEDICARE
042472266OtherTHREE RIVERS
8300457OtherEVERCARE
AP0289OtherBLUE SHIELD INDEMNITY
9900373OtherFALLON COMMUNITY HEALTH P
MA110123231AMedicaid