Provider Demographics
NPI:1356362776
Name:WIERSMA, SUSAN R (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:R
Last Name:WIERSMA
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 1:3605 WARRENSVILLE CENTER RD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5203
Mailing Address - Country:US
Mailing Address - Phone:216-286-6299
Mailing Address - Fax:216-286-6341
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-7700
Practice Address - Fax:216-286-6341
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0510502080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH742534OtherBUCKEYE
OK200206560AOtherOK MEDICAID
OH2056126Medicaid
OH364131OtherWELLCARE
OH000000221140OtherUNISON
OH000000027183OtherANTHEM
OH000000526169OtherANTHEM
OH2056126OtherBCMH
OH2093513OtherAETNA
OH000000027183OtherANTHEM
OH000000221140OtherUNISON
OH364131OtherWELLCARE