Provider Demographics
NPI:1710365473
Name:MEDALIE, SUSAN RACHEL (DO)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:RACHEL
Last Name:MEDALIE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 MACK BLVD FL 4
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-5622
Mailing Address - Country:US
Mailing Address - Phone:570-790-2391
Mailing Address - Fax:
Practice Address - Street 1:200 SCHUYLKILL MEDICAL PLZ
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-3660
Practice Address - Country:US
Practice Address - Phone:570-621-9270
Practice Address - Fax:570-621-9271
Is Sole Proprietor?:No
Enumeration Date:2015-05-14
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS018728207Q00000X, 207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program