Provider Demographics
NPI:1902849979
Name:OSTERTAG, SUSAN G (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:G
Last Name:OSTERTAG
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 1599
Mailing Address - Street 2:PENOBSCOT COMMUNITY HEALTH CENTER
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-1599
Mailing Address - Country:US
Mailing Address - Phone:207-945-5247
Mailing Address - Fax:
Practice Address - Street 1:992 UNION ST
Practice Address - Street 2:PENOBSCOT COMMUNITY HEALTH CENTER
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3057
Practice Address - Country:US
Practice Address - Phone:207-945-5247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME013665207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM5247Medicare ID - Type Unspecified
MEMM524701Medicare PIN
MEMM524702Medicare PIN
MEF74246Medicare UPIN
MEMM9086Medicare PIN