Provider Demographics
NPI:1841288719
Name:KOELLIKER, SUSAN LYN (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYN
Last Name:KOELLIKER
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 1:125 METRO CENTER BLVD STE 2000
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-1785
Mailing Address - Country:US
Mailing Address - Phone:401-432-2520
Mailing Address - Fax:401-921-9212
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-5174
Practice Address - Fax:401-921-9212
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1541792085R0202X
RIMD088652085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
005220OtherBLUECHIP
403111OtherTUFTS
007004713OtherHOSPITAL PIN
1600203OtherUNITEDHEALTHPLANS
3199894OtherMASSMEDICAID
720053201OtherCIGNA
3199894OtherHEALTHYSTART
7004715OtherRIMEDICALASSISTANCE
000000001988OtherNHPRI
003111482OtherCT MED ASSISTANCE
008865OtherBLUESHIELD
007004715OtherMEDICARE
240171OtherRJHPILGRIM
300067448OtherRAILROAD MEDICARE