Provider Demographics
NPI:1740592997
Name:GHANNAM, SUZANNE M (MD)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:M
Last Name:GHANNAM
Suffix:
Gender:U
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 4661
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25364-4661
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:304-606-6100
Practice Address - Street 1:PO BOX 4661
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25364-4661
Practice Address - Country:US
Practice Address - Phone:304-606-6100
Practice Address - Fax:304-606-6100
Is Sole Proprietor?:No
Enumeration Date:2010-07-03
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1544582085R0202X, 208D00000X, 208D00000X
ZZZZ207U00000X, 207UN0902X, 2085N0904X, 2085U0001X, 208600000X, 209800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
No207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & Therapy
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No209800000XAllopathic & Osteopathic PhysiciansLegal Medicine