Healthcare Provider Details

I. General information

NPI: 1770665143
Provider Name (Legal Business Name): SUSAN RUCKER MIHM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 08/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 MIAMI AVE EAST
VENICE FL
34285
US

IV. Provider business mailing address

PO BOX 863407
ORLANDO FL
32886-3407
US

V. Phone/Fax

Practice location:
  • Phone: 941-480-0088
  • Fax: 941-480-0006
Mailing address:
  • Phone: 941-917-2600
  • Fax: 941-917-7884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME68443
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: