Provider Demographics
NPI:1679669899
Name:PANTELYAT, SUSANNA (MD)
Entity Type:Individual
Prefix:
First Name:SUSANNA
Middle Name:
Last Name:PANTELYAT
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 1:2112 WELSH RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115
Mailing Address - Country:US
Mailing Address - Phone:215-673-1498
Mailing Address - Fax:215-673-4299
Practice Address - Street 1:2112 WELSH RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115
Practice Address - Country:US
Practice Address - Phone:215-673-1498
Practice Address - Fax:215-673-4299
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4173372084N0400X
NJ25MA073820002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA30009182OtherKEYSTONE MERCY
PAA3226157OtherAETNA
PA001871360Medicaid
PA001871360Medicaid
PAA3226157OtherAETNA