Provider Demographics
NPI:1437112422
Name:MULLIGAN, SUSAN ANDREA (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ANDREA
Last Name:MULLIGAN
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 1:975 JOHNSON FERRY RD NE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-4737
Mailing Address - Country:US
Mailing Address - Phone:404-255-8086
Mailing Address - Fax:
Practice Address - Street 1:975 JOHNSON FERRY RD NE
Practice Address - Street 2:SUITE 500
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-4737
Practice Address - Country:US
Practice Address - Phone:404-255-8086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL124252085R0202X
GA580842085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51521669OtherBLUE CROSS/BLUE SHIELD
AL300015346OtherRAILROAD MEDICARE
AL51521668OtherBLUE CROSS/BLUE SHIELD
GA748293523AMedicaid
AL300015346OtherRAILROAD MEDICARE
AL51521669OtherBLUE CROSS/BLUE SHIELD
GA30BDMXSMedicare ID - Type UnspecifiedGEORGIA MEDICARE