Provider Demographics
NPI:1982961751
Name:TUCKER, SUSAN REBECCA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:REBECCA
Last Name:TUCKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:REBECCA
Other - Last Name:MCMAHON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3515 MASSILLON RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:UNIONTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44685-6400
Mailing Address - Country:US
Mailing Address - Phone:330-899-9350
Mailing Address - Fax:330-634-1329
Practice Address - Street 1:65 COMMUNITY RD
Practice Address - Street 2:SUITE C
Practice Address - City:TALLMADGE
Practice Address - State:OH
Practice Address - Zip Code:44278-2358
Practice Address - Country:US
Practice Address - Phone:330-633-6601
Practice Address - Fax:330-633-4476
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35125325207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0121930Medicaid
OH0121930Medicaid