Provider Demographics
NPI:1518073048
Name:OH SUSANNAH LLC
Entity Type:Organization
Organization Name:OH SUSANNAH LLC
Other - Org Name:DBA PHYSICIAN CHOICE; DBA PINK RIBBON MASTECTOMY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MORELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-829-5440
Mailing Address - Street 1:101 S SKIPPER DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-7446
Mailing Address - Country:US
Mailing Address - Phone:210-829-5440
Mailing Address - Fax:210-828-3698
Practice Address - Street 1:332 W SUNSET RD
Practice Address - Street 2:SUITE 2-B
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-1767
Practice Address - Country:US
Practice Address - Phone:210-829-5440
Practice Address - Fax:210-828-3698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1814717-02Medicaid
TX1814717-01Medicaid
TX1814717-02Medicaid