Provider Demographics
NPI: | 1932195013 |
---|---|
Name: | GLANDER, SUSAN STEPHEN (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | SUSAN |
Middle Name: | STEPHEN |
Last Name: | GLANDER |
Suffix: | |
Gender: | F |
Credentials: | MD |
Other - Prefix: | DR |
Other - First Name: | SUSAN |
Other - Middle Name: | JANIS |
Other - Last Name: | GLANDER |
Other - Suffix: | |
Other - Last Name Type: | Other Name |
Other - Credentials: | MD |
Mailing Address - Street 1: | 5780 PEACHTREE DUNWOODY ROAD |
Mailing Address - Street 2: | SUITE 300 |
Mailing Address - City: | ATLANTA |
Mailing Address - State: | GA |
Mailing Address - Zip Code: | 30342-1513 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 404-303-1224 |
Mailing Address - Fax: | 404-303-1325 |
Practice Address - Street 1: | 1121 JOHNSON FERRY RD |
Practice Address - Street 2: | SUITE 150 |
Practice Address - City: | MARIETTA |
Practice Address - State: | GA |
Practice Address - Zip Code: | 30068-5425 |
Practice Address - Country: | US |
Practice Address - Phone: | 770-977-1510 |
Practice Address - Fax: | 770-509-8858 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-09-23 |
Last Update Date: | 2016-06-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
GA | 042579 | 207VG0400X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207VG0400X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
GA | 000656565M | Medicaid | |
GA | 000656565K | Medicaid | |
GA | 000656565L | Medicaid | |
GA | G72851 | Medicare UPIN |