Provider Demographics
NPI:1588658538
Name:WYSE, SUSIE (MD)
Entity Type:Individual
Prefix:
First Name:SUSIE
Middle Name:
Last Name:WYSE
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 1:2203 EAGLES NEST CIR
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-7024
Mailing Address - Country:US
Mailing Address - Phone:419-625-1343
Mailing Address - Fax:
Practice Address - Street 1:1101 DECATUR ST
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-3335
Practice Address - Country:US
Practice Address - Phone:419-626-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35052248W207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0674800Medicaid
OH0674800Medicaid
OHWY0753882Medicare ID - Type Unspecified