MEDICARE: DR. SUSAN MARY MANSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	ME100442	FL
2	207R00000X	Internal Medicine Physician	314541	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467407635
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN MARY MANSON MD

Provider Business Mailing Address
First Line	:	2547 LAKEFAIR DR
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32317-7002
Country	:	US
Telephone Number	:	850-491-2326
Fax Number	:

Provider Business Practice Location Address
First Line	:	510 TOWNE DR
Second Line	:
City	:	FAYETTEVILLE
State	:	NY
Zip	:	13066-1331
Country	:	US
Telephone Number	:	315-627-0448
Fax Number	:	315-627-0554

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2006
Last Update Date	:	11/15/2022

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