Provider Demographics
NPI:1841294493
Name:SUSLICK, RANDALL H (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:H
Last Name:SUSLICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:946 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHASE CITY
Mailing Address - State:VA
Mailing Address - Zip Code:23924-1139
Mailing Address - Country:US
Mailing Address - Phone:434-372-5141
Mailing Address - Fax:434-372-8910
Practice Address - Street 1:946 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CHASE CITY
Practice Address - State:VA
Practice Address - Zip Code:23924-1139
Practice Address - Country:US
Practice Address - Phone:434-372-5141
Practice Address - Fax:434-372-8910
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101032102207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007610114Medicaid
VA1841294493Medicare PIN
VA007610114Medicaid