Provider Demographics
NPI:1801008289
Name:SUSAN M SANDRIDGE
Entity type:Organization
Organization Name:SUSAN M SANDRIDGE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:SANDRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:BFA
Authorized Official - Phone:208-233-4748
Mailing Address - Street 1:PO BOX 423
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-0423
Mailing Address - Country:US
Mailing Address - Phone:208-233-4748
Mailing Address - Fax:
Practice Address - Street 1:1255 E WHITMAN
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5748
Practice Address - Country:US
Practice Address - Phone:208-233-4748
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-05
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806009700Medicaid
ID806009800Medicaid