Provider Demographics
NPI:1477158681
Name:FORSYTH, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:FORSYTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 NEW MILFORD RD
Mailing Address - Street 2:
Mailing Address - City:ATWATER
Mailing Address - State:OH
Mailing Address - Zip Code:44201-7702
Mailing Address - Country:US
Mailing Address - Phone:330-618-4736
Mailing Address - Fax:
Practice Address - Street 1:1809 NEW MILFORD RD
Practice Address - Street 2:
Practice Address - City:ATWATER
Practice Address - State:OH
Practice Address - Zip Code:44201-7702
Practice Address - Country:US
Practice Address - Phone:330-618-4736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0369871Medicaid