Healthcare Provider Details

I. General information

NPI: 1558926675
Provider Name (Legal Business Name): THOMAS TONY SUSI JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2019
Last Update Date: 05/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E ROBINSON ST STE 220
ORLANDO FL
32801-4368
US

IV. Provider business mailing address

82 LINTON RD
PONCE DE LEON FL
32455-3732
US

V. Phone/Fax

Practice location:
  • Phone: 407-380-9998
  • Fax:
Mailing address:
  • Phone: 850-428-3570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN9302252
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: