Provider Demographics
NPI:1346217361
Name:NIEMELA, SUZANNE WILLARD (MD)
Entity Type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:WILLARD
Last Name:NIEMELA
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 12622
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4017
Mailing Address - Country:US
Mailing Address - Phone:443-481-6577
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:1630 MAIN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:CHESTER
Practice Address - State:MD
Practice Address - Zip Code:21619-2791
Practice Address - Country:US
Practice Address - Phone:410-604-6591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0047311207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD53450302OtherCAREFIRST
MD371201000Medicaid
DCJ1740002OtherCAREFIRST
DCJ1740002OtherCAREFIRST
MD796MMedicare ID - Type Unspecified
MD371201000Medicaid