MEDICARE: DR. SUSAN A INNISS 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	207ZP0105X	Clinical Pathology/Laboratory Medicine Physician	MD057153L	PA

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588652531
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN A INNISS MD

Provider Business Mailing Address
First Line	:	132 S 10TH ST
Second Line	:	285K, 2ND FLOOR
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-5244
Country	:	US
Telephone Number	:	215-503-5642
Fax Number	:	215-503-4817

Provider Business Practice Location Address
First Line	:	132 S 10TH ST
Second Line	:	285K, 2ND FLOOR
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-5244
Country	:	US
Telephone Number	:	215-503-5642
Fax Number	:	215-503-4817

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

Provider Enumeration Date	:	10/12/2005
Last Update Date	:	06/09/2016

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