Provider Demographics
NPI:1407055874
Name:SUSAN C FAIR DO PA
Entity Type:Organization
Organization Name:SUSAN C FAIR DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:FAIR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:321-455-1226
Mailing Address - Street 1:595 N COURTENAY PKWY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4851
Mailing Address - Country:US
Mailing Address - Phone:321-455-1226
Mailing Address - Fax:321-456-5531
Practice Address - Street 1:595 N COURTENAY PKWY
Practice Address - Street 2:SUITE 102
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4851
Practice Address - Country:US
Practice Address - Phone:321-455-1226
Practice Address - Fax:321-456-5531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7489207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS7489OtherMEDICAL LICENSE