Provider Demographics
NPI:1750345278
Name:MCGILLIS, SUSAN TERI (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:TERI
Last Name:MCGILLIS
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 1:230 HARRISBURG AVE
Mailing Address - Street 2:STE 4
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603-2959
Mailing Address - Country:US
Mailing Address - Phone:717-399-9800
Mailing Address - Fax:717-399-7613
Practice Address - Street 1:230 HARRISBURG AVE
Practice Address - Street 2:STE 4
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17603-2959
Practice Address - Country:US
Practice Address - Phone:717-399-9800
Practice Address - Fax:717-399-7613
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35058536M207N00000X
PAMD430176207ND0101X, 207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0761046Medicaid
OH0761046Medicaid