Provider Demographics
NPI:1679542708
Name:SUSSMAN, TED L (MD)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:L
Last Name:SUSSMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 HARTFORD ST
Mailing Address - Street 2:
Mailing Address - City:HOULTON
Mailing Address - State:ME
Mailing Address - Zip Code:04730-1891
Mailing Address - Country:US
Mailing Address - Phone:207-532-2900
Mailing Address - Fax:207-532-5974
Practice Address - Street 1:22 HARTFORD ST
Practice Address - Street 2:SIGRID E TOMPKINS HEALTH CENTER
Practice Address - City:HOULTON
Practice Address - State:ME
Practice Address - Zip Code:04730-1844
Practice Address - Country:US
Practice Address - Phone:207-532-4068
Practice Address - Fax:207-532-5974
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD10269207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
METEME18OtherMEDICARE - PACER CLINIC
METEME18OtherMEDICARE - PACER CLINIC
054249Medicare PIN