Provider Demographics
NPI:1770518623
Name:SMITH, SUSAN O (NP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:O
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVE
Mailing Address - Street 2:BOX 670
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-275-7944
Mailing Address - Fax:585-244-0502
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-0002
Practice Address - Country:US
Practice Address - Phone:585-275-7944
Practice Address - Fax:585-244-0502
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY443130163W00000X
NY301476363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02443209Medicaid
RB1303Medicare PIN
NY02443209Medicaid
NYCC3415Medicare ID - Type Unspecified