Provider Demographics
NPI:1952480527
Name:ETHERIDGE, SUSAN P (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:P
Last Name:ETHERIDGE
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 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:305 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6231
Practice Address - Country:US
Practice Address - Phone:208-381-7370
Practice Address - Fax:208-381-7387
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-17302207RC0001X
AK8186207RC0001X, 208000000X
UT273593-12052080P0202X, 207RC0001X, 208000000X
AK83892080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1018632Medicaid
AKK165892Medicare PIN