Healthcare Provider Details

I. General information

NPI: 1518459809
Provider Name (Legal Business Name): SU MON AYE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2018
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2230 COTTMAN AVE
PHILADELPHIA PA
19149-1230
US

IV. Provider business mailing address

2230 COTTMAN AVE
PHILADELPHIA PA
19149-1230
US

V. Phone/Fax

Practice location:
  • Phone: 215-685-0603
  • Fax: 215-725-4877
Mailing address:
  • Phone: 215-685-0603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0100709
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD474685
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC1-0027045
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: