Provider Demographics
NPI:1255365920
Name:HERMAN, SUSAN T (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:T
Last Name:HERMAN
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 1:240 W THOMAS RD # 301
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4407
Mailing Address - Country:US
Mailing Address - Phone:602-406-6262
Mailing Address - Fax:617-632-8931
Practice Address - Street 1:240 W THOMAS RD # 403
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4407
Practice Address - Country:US
Practice Address - Phone:602-406-6262
Practice Address - Fax:602-406-6261
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2374382084N0400X, 2084N0600X
AZ587422084N0400X, 2084E0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084E0001XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyEpilepsy
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018832530001Medicaid
G93223Medicare UPIN
PA0018832530001Medicaid