Provider Demographics
NPI:1336211796
Name:WOMELDORF, SUSAN M (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:WOMELDORF
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 1:11110 MEDICAL CAMPUS RD STE 147
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-6755
Mailing Address - Country:US
Mailing Address - Phone:240-313-9100
Mailing Address - Fax:240-313-9601
Practice Address - Street 1:13424 PA AVE
Practice Address - Street 2:MERRITUS URGENT CARE
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-2658
Practice Address - Country:US
Practice Address - Phone:240-313-3100
Practice Address - Fax:210-313-3101
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21508207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP00418711OtherRAILROAD
MD409353401Medicaid
MD451601000Medicaid
WV3810003919Medicaid
WV7340231Medicare ID - Type Unspecified
MDR299Medicare PIN
MD613LR299Medicare PIN