Provider Demographics
NPI:1770523870
Name:EVANS, SUSANNA G (MD)
Entity type:Individual
Prefix:
First Name:SUSANNA
Middle Name:G
Last Name:EVANS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1601 CHERRY ST
Mailing Address - Street 2:SUITE 11511
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-1321
Mailing Address - Country:US
Mailing Address - Phone:215-255-7822
Mailing Address - Fax:
Practice Address - Street 1:10 SHURS LN
Practice Address - Street 2:SUITE 409
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19127-2123
Practice Address - Country:US
Practice Address - Phone:215-482-1234
Practice Address - Fax:215-482-0465
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD417655207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA8649657OtherCIGNA HMO/PPO
PA2105709000OtherIBC - PC/KHPE
PA1163241OtherKEYSTONE MERCY
PA17713-MD417655OtherHEALTH PARTNERS
PA2105709000OtherAMERIHEALTH/INTERCOUNTY
PA10926381OtherCAQH ID#
PA080191559OtherRRM
PA1419348OtherHIGHMARK BLUE SHIELD
PA4641104OtherAETNA PPO
PA0189959402OtherAMERICHOICE (UHC MA PLAN)
PA0018995940001Medicaid
PA2999717OtherAETNA HMO
PA1163241OtherKEYSTONE MERCY
PA1163241OtherKEYSTONE MERCY