Provider Demographics
NPI:1477500783
Name:PATRICK-MACKINNON, SUSANNE J (MD)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:J
Last Name:PATRICK-MACKINNON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MILL RD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-5252
Mailing Address - Country:US
Mailing Address - Phone:508-973-2000
Mailing Address - Fax:508-973-2001
Practice Address - Street 1:2444 E MAIN RD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:RI
Practice Address - Zip Code:02871-4025
Practice Address - Country:US
Practice Address - Phone:401-683-1048
Practice Address - Fax:401-683-1239
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD090302084N0400X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7005007Medicaid
RI0070103702Medicare PIN