Healthcare Provider Details

I. General information

NPI: 1043291917
Provider Name (Legal Business Name): SUSAN LEE HUBBELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 02/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

939 W MARKET ST STE 1
LIMA OH
45805-2738
US

IV. Provider business mailing address

939 W MARKET ST STE 1
LIMA OH
45805-2738
US

V. Phone/Fax

Practice location:
  • Phone: 419-228-5434
  • Fax: 419-228-4620
Mailing address:
  • Phone: 419-228-5434
  • Fax: 419-228-4620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number35-04-1078
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier250001154
Identifier TypeOTHER
Identifier State
Identifier IssuerRAILROAD MEDICARE
# 2
Identifier000000120843
Identifier TypeOTHER
Identifier State
Identifier IssuerBLUE SHIELD
# 3
Identifier0432277
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer
# 4
Identifier341526576 00
Identifier TypeOTHER
Identifier StateOH
Identifier IssuerWC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: