Provider Demographics
NPI:1780613489
Name:RABEN-TAYLOR, SUSAN L (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:L
Last Name:RABEN-TAYLOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:L
Other - Last Name:RABEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:525 N GARLAND AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-3110
Mailing Address - Country:US
Mailing Address - Phone:870-424-5079
Mailing Address - Fax:870-424-8455
Practice Address - Street 1:525 N GARLAND AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-3110
Practice Address - Country:US
Practice Address - Phone:479-582-1755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN-7882207QS0010X, 208VP0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR12990OtherQUALCHOICE INSURANCE ID#
AR12990OtherQUALCHOICE INSURANCE ID#
ARD71471Medicare UPIN