Provider Demographics
NPI:1952825259
Name:SUSAN CULVERHOUSE, MD PA
Entity Type:Organization
Organization Name:SUSAN CULVERHOUSE, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD / PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:CULVERHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-784-3746
Mailing Address - Street 1:707 E CERVANTES ST, SUITE B #298
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501
Mailing Address - Country:US
Mailing Address - Phone:407-272-4232
Mailing Address - Fax:
Practice Address - Street 1:801 E 6TH ST STE 201
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-3667
Practice Address - Country:US
Practice Address - Phone:850-763-8680
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-28
Last Update Date:2017-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME106708261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009329900Medicaid