Provider Demographics
NPI:1649346925
Name:TENNEY, SUETTA (MD)
Entity type:Individual
Prefix:
First Name:SUETTA
Middle Name:
Last Name:TENNEY
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:PO BOX 42738
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21284-2738
Mailing Address - Country:US
Mailing Address - Phone:410-494-7607
Mailing Address - Fax:610-925-7387
Practice Address - Street 1:GENESIS HEALTH CARE WINWARD GARDENS NURSING CENTER
Practice Address - Street 2:105 MECHANIC STREET
Practice Address - City:CAMDEN
Practice Address - State:ME
Practice Address - Zip Code:04843
Practice Address - Country:US
Practice Address - Phone:207-236-4197
Practice Address - Fax:207-230-0563
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD22576207R00000X
MA71345207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3002764Medicaid
69626OtherHARVARD PILGRAM
71345OtherMASS LICENSE #
712914OtherTUETS HEALTH PLAN
0701800OtherBC BS ANTHEM
4978OtherFALLON
110229385OtherRAILROAD MEDICARE
110229385OtherRAILROAD MEDICARE
0701800OtherBC BS ANTHEM
71345OtherMASS LICENSE #