Provider Demographics
NPI:1730137035
Name:FISHER, SUSAN G (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:G
Last Name:FISHER
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:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:TN
Mailing Address - Zip Code:37307-0308
Mailing Address - Country:US
Mailing Address - Phone:423-338-8995
Mailing Address - Fax:423-338-8996
Practice Address - Street 1:6784 HIGHWAY 411
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:TN
Practice Address - Zip Code:37307-4818
Practice Address - Country:US
Practice Address - Phone:423-338-8995
Practice Address - Fax:423-338-8996
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000023627207R00000X
TN23627207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3017637OtherBLUE CROSS BLUE SHIELD
TND51404Medicare UPIN
TN3709126Medicare ID - Type UnspecifiedMEDICARE PROVIDER