Provider Demographics
NPI:1578710802
Name:TED L SUSSMAN
Entity Type:Organization
Organization Name:TED L SUSSMAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TED
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:SUSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:207-532-7671
Mailing Address - Street 1:PO BOX 695
Mailing Address - Street 2:
Mailing Address - City:HOULTON
Mailing Address - State:ME
Mailing Address - Zip Code:04730-0695
Mailing Address - Country:US
Mailing Address - Phone:207-532-7671
Mailing Address - Fax:207-532-7671
Practice Address - Street 1:20 HARTFORD ST
Practice Address - Street 2:
Practice Address - City:HOULTON
Practice Address - State:ME
Practice Address - Zip Code:04730-1891
Practice Address - Country:US
Practice Address - Phone:207-532-7671
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME010269171R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171R00000XOther Service ProvidersInterpreterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEME1883OtherMEDICARE-PACER CLINIC
ME293380099Medicaid
B86361Medicare UPIN