Provider Demographics
NPI:1588652531
Name:INNISS, SUSAN A (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:A
Last Name:INNISS
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 1:132 S 10TH ST
Mailing Address - Street 2:285K, 2ND FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5244
Mailing Address - Country:US
Mailing Address - Phone:215-503-5642
Mailing Address - Fax:215-503-4817
Practice Address - Street 1:132 S 10TH ST
Practice Address - Street 2:285K, 2ND FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5244
Practice Address - Country:US
Practice Address - Phone:215-503-5642
Practice Address - Fax:215-503-4817
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD057153L207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001635756Medicaid
PA10052005426152Medicaid
PA10052005426152Medicaid
PA019869Medicare PIN