Provider Demographics
NPI:1902867781
Name:HENLEY, SUSAN J (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:HENLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1501 SULGRAVE AVE
Mailing Address - Street 2:STE 306
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-3651
Mailing Address - Country:US
Mailing Address - Phone:410-433-8801
Mailing Address - Fax:410-433-8803
Practice Address - Street 1:1501 SULGRAVE AVE
Practice Address - Street 2:STE 306
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-3651
Practice Address - Country:US
Practice Address - Phone:410-433-8801
Practice Address - Fax:410-433-8801
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2016-02-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MDD0043591207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD191361100Medicaid
MD329RMedicare PIN
F53376Medicare UPIN