Healthcare Provider Details

I. General information

NPI: 1255344438
Provider Name (Legal Business Name): SUSAN C NICOLSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 04/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34TH STREET & CIVIC CENTER BLVD SUITE 9329
PHILADELPHIA PA
19104-4399
US

IV. Provider business mailing address

100 E PENN SQ THE WANAMAKER BUILDING, 9TH FLOOR
PHILADELPHIA PA
19107-3323
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-1867
  • Fax: 215-590-5824
Mailing address:
  • Phone: 297-425-9300
  • Fax: 297-425-9331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD024170E
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMD024170E
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License NumberMD024170E
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD024170E
License Number StatePA
# 5
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberMD024170E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: