Provider Demographics
NPI:1265458053
Name:POWELL, SUZANNE VICTORIA (MD)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:VICTORIA
Last Name:POWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:141 SIEGLER ST
Mailing Address - Street 2:DEPT OF VETERANS AFFAIRS
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-2635
Mailing Address - Country:US
Mailing Address - Phone:920-497-3126
Mailing Address - Fax:920-497-3176
Practice Address - Street 1:141 SIEGLER ST
Practice Address - Street 2:DEPT OF VETERANS AFFAIRS
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2635
Practice Address - Country:US
Practice Address - Phone:920-497-3126
Practice Address - Fax:920-497-3176
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI44341208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34275300Medicaid
H73812Medicare UPIN
WI34275300Medicaid