Provider Demographics
NPI:1750480802
Name:MORENO, SUSAN I (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:I
Last Name:MORENO
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 1:196 GROVE AVE SUITE E
Mailing Address - Street 2:
Mailing Address - City:THOROFARE
Mailing Address - State:NJ
Mailing Address - Zip Code:08086
Mailing Address - Country:US
Mailing Address - Phone:856-845-2323
Mailing Address - Fax:856-845-4888
Practice Address - Street 1:196 GROVE AVE SUITE E
Practice Address - Street 2:
Practice Address - City:THOROFARE
Practice Address - State:NJ
Practice Address - Zip Code:08086
Practice Address - Country:US
Practice Address - Phone:856-845-2323
Practice Address - Fax:856-845-4888
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA05706900208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
722323OtherAMERIHEALTH PC
P2681709OtherOXFORD HEALTH PLAN NOT IN
004117179OtherFAMILY HEALTH PROV SELECT
363879700OtherDEPT OF LABOR WORKMANS CO
722323OtherPABS PC
1697844001OtherCIGNA
2162090OtherAETNA IN NETWORK WITH OPE
223671610OtherDEVON
G22323OtherAMERI ADMIN
1K8338OtherHEALTHNET HMO PLANS ALSO
250012005OtherRR MEDICARE
363879700OtherACS DOL
722323OtherHORINZON BCBS NJ DIRECT A
0509463000OtherKEYSTONE AMERI BCBS
905513OtherFIRSH HEALTH
722323OtherAMERIHEALTH PC
721074Medicare ID - Type Unspecified