Provider Demographics
NPI:1376732859
Name:SUSQUEHANNA MEDICAL ASSOCIATES, LLP.
Entity Type:Organization
Organization Name:SUSQUEHANNA MEDICAL ASSOCIATES, LLP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:A
Authorized Official - Last Name:GIMINARO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:410-569-4144
Mailing Address - Street 1:2012 S TOLLGATE RD
Mailing Address - Street 2:111
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21015-5900
Mailing Address - Country:US
Mailing Address - Phone:410-569-4144
Mailing Address - Fax:410-569-4147
Practice Address - Street 1:2012 S TOLLGATE RD
Practice Address - Street 2:111
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21015-5900
Practice Address - Country:US
Practice Address - Phone:410-569-4144
Practice Address - Fax:410-569-4147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0054439207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD000241100Medicaid
MD000241100Medicaid