Provider Demographics
NPI:1578531182
Name:EHRENTHAL, SUSAN R (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:R
Last Name:EHRENTHAL
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 1:311 SERVICE RD
Mailing Address - Street 2:
Mailing Address - City:EAST SANDWICH
Mailing Address - State:MA
Mailing Address - Zip Code:02537-1370
Mailing Address - Country:US
Mailing Address - Phone:508-833-4172
Mailing Address - Fax:508-833-4202
Practice Address - Street 1:311 SERVICE RD
Practice Address - Street 2:
Practice Address - City:EAST SANDWICH
Practice Address - State:MA
Practice Address - Zip Code:02537-1370
Practice Address - Country:US
Practice Address - Phone:508-833-4172
Practice Address - Fax:508-833-4202
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA78318208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3133494Medicaid
MAJ330952Medicare ID - Type Unspecified
MAF68043Medicare UPIN