Provider Demographics
NPI:1720083041
Name:KIM-MAULSBY, SUSIE H (MD)
Entity Type:Individual
Prefix:
First Name:SUSIE
Middle Name:H
Last Name:KIM-MAULSBY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUSIE
Other - Middle Name:HYUN
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5400 KENNEDY AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45213-2664
Mailing Address - Country:US
Mailing Address - Phone:513-281-3400
Mailing Address - Fax:513-527-2275
Practice Address - Street 1:5400 KENNEDY AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45213-2664
Practice Address - Country:US
Practice Address - Phone:513-281-3400
Practice Address - Fax:513-527-2275
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0789382085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL271414100Medicaid
KY64086820Medicaid
OH2311751Medicaid
KY64086820Medicaid