Provider Demographics
NPI:1336137249
Name:SUSI, AITA KAI (MD)
Entity Type:Individual
Prefix:
First Name:AITA
Middle Name:KAI
Last Name:SUSI
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 1:3425 N CARLISLE ST
Mailing Address - Street 2:2ND FL HUDSON BUILDING
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140
Mailing Address - Country:US
Mailing Address - Phone:215-707-4739
Mailing Address - Fax:215-707-3677
Practice Address - Street 1:3509 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140
Practice Address - Country:US
Practice Address - Phone:215-707-5437
Practice Address - Fax:215-707-5180
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD053877L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001548356Medicaid
PA340035FPXOtherMEDICARE PTAN
PA001548356Medicaid