Provider Demographics
NPI:1245201334
Name:CONWAY, SUSAN (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:CONWAY
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 1:5445 MERIDIAN MARKS RD NE
Mailing Address - Street 2:SUITE 270
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-4763
Mailing Address - Country:US
Mailing Address - Phone:404-843-2229
Mailing Address - Fax:404-843-0812
Practice Address - Street 1:206 E FARREL RD STE 270
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-7104
Practice Address - Country:US
Practice Address - Phone:337-989-8795
Practice Address - Fax:404-843-0812
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA54192174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA54192OtherGA STATE LICENSE
GAG56510Medicare UPIN