Provider Demographics
NPI:1831154103
Name:HARRELL, SUSAN (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:HARRELL
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 1:1100 LAKE HEARN DR NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1523
Mailing Address - Country:US
Mailing Address - Phone:404-256-3178
Mailing Address - Fax:404-256-3583
Practice Address - Street 1:1100 LAKE HEARN DR NE
Practice Address - Street 2:SUITE 100
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1523
Practice Address - Country:US
Practice Address - Phone:404-256-3178
Practice Address - Fax:404-256-3583
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033100208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
4289398OtherAETNA CAPITATED
40468OtherGREAT WEST
55091OtherAETNA
257740OtherBLUE CROSS BLUE SHIELD
691302OtherCIGNA HEALTHCARE