Provider Demographics
NPI: | 1710175179 |
---|---|
Name: | FLICK, SUSAN M (CNP) |
Entity Type: | Individual |
Prefix: | MRS |
First Name: | SUSAN |
Middle Name: | M |
Last Name: | FLICK |
Suffix: | |
Gender: | F |
Credentials: | CNP |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 11100 EUCLID AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | CLEVELAND |
Mailing Address - State: | OH |
Mailing Address - Zip Code: | 44106-1716 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 216-844-3009 |
Mailing Address - Fax: | 216-844-1900 |
Practice Address - Street 1: | 11100 EUCLID AVE |
Practice Address - Street 2: | LAKESIDE 4TH FLOOR UROLOGY SUITE |
Practice Address - City: | CLEVELAND |
Practice Address - State: | OH |
Practice Address - Zip Code: | 44106-1716 |
Practice Address - Country: | US |
Practice Address - Phone: | 216-844-3085 |
Practice Address - Fax: | 216-844-7735 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-10-11 |
Last Update Date: | 2021-01-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OH | 09704NP | 363LA2200X |
OH | COA.09704-NP | 363LA2200X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LA2200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OH | 464794 | Other | WELLCARE |
OH | 2839343 | Medicaid | |
OH | FLNP28141 | Medicare PIN | |
OH | 464794 | Other | WELLCARE |