Provider Demographics
NPI:1942319835
Name:STEIN, SUSAN (N P)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:STEIN
Suffix:
Gender:F
Credentials:N P
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 270
Mailing Address - Street 2:
Mailing Address - City:PAOLI
Mailing Address - State:IN
Mailing Address - Zip Code:47454-0270
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:170 SOUTH SECOND STREET
Practice Address - Street 2:
Practice Address - City:MARENGO
Practice Address - State:IN
Practice Address - Zip Code:47140
Practice Address - Country:US
Practice Address - Phone:812-365-3221
Practice Address - Fax:812-365-9502
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000123A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200080850AMedicaid
INR33353Medicare UPIN
IN600490IMedicare ID - Type Unspecified