Provider Demographics
NPI:1487643037
Name:BRALEY, SUSAN E (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:BRALEY
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:PO BOX 636256 CENTRAL CREDENTIALING
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6256
Mailing Address - Country:US
Mailing Address - Phone:513-245-3107
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:234 GOODMAN ST
Practice Address - Street 2:ML 0761
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45267-1000
Practice Address - Country:US
Practice Address - Phone:513-584-4391
Practice Address - Fax:513-584-0431
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-06-21552085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200039480AMedicaid
OH0843798Medicaid
KY64868219Medicaid
OH1620954OtherUNITED HEALTHCARE
OH655258OtherAETNA
OH000000013880OtherANTHEM
OH655258OtherAETNA
OHBR0701491Medicare ID - Type Unspecified