Provider Demographics
NPI:1689810434
Name:OH SUSANNAH
Entity Type:Organization
Organization Name:OH SUSANNAH
Other - Org Name:PHYSICIAN CHOICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MORELAND
Authorized Official - Suffix:
Authorized Official - Credentials:N/A
Authorized Official - Phone:210-386-2296
Mailing Address - Street 1:101 S SKIPPER DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-7446
Mailing Address - Country:US
Mailing Address - Phone:210-386-2296
Mailing Address - Fax:210-828-3698
Practice Address - Street 1:1100 NW LOOP 410
Practice Address - Street 2:SUITE 700
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78213-2263
Practice Address - Country:US
Practice Address - Phone:210-386-2296
Practice Address - Fax:210-828-3698
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OH SUSANNAH LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-29
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX181471702Medicaid
TX5292450001Medicare NSC