Provider Demographics
NPI:1861820599
Name:SUSSMAN, MICHAEL LORNE
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LORNE
Last Name:SUSSMAN
Suffix:
Gender:M
Credentials:
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 37803
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19101-0103
Mailing Address - Country:US
Mailing Address - Phone:800-507-8874
Mailing Address - Fax:727-536-2896
Practice Address - Street 1:119 OAKFIELD DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5779
Practice Address - Country:US
Practice Address - Phone:813-571-5100
Practice Address - Fax:813-653-7025
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-15
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107280363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant