Provider Demographics
NPI:1659356806
Name:GIN-SHAW, SUSAN L (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:L
Last Name:GIN-SHAW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:L
Other - Last Name:GIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1632 N 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85007-1708
Mailing Address - Country:US
Mailing Address - Phone:602-689-0638
Mailing Address - Fax:
Practice Address - Street 1:19829 N 27TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-4001
Practice Address - Country:US
Practice Address - Phone:623-879-5445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17053207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00266840OtherRAILROAD MEDICARE
AZ293358Medicaid
AZ86080015085259A283OtherTRIWEST
E39612Medicare UPIN
AZ293358Medicaid