Healthcare Provider Details

I. General information

NPI: 1346217361
Provider Name (Legal Business Name): SUZANNE WILLARD NIEMELA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 06/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 MAIN ST SUITE 101
CHESTER MD
21619-2791
US

IV. Provider business mailing address

PO BOX 12622
BELFAST ME
04915-4017
US

V. Phone/Fax

Practice location:
  • Phone: 410-604-6591
  • Fax:
Mailing address:
  • Phone: 443-481-6577
  • Fax: 443-481-6515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0047311
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: