Healthcare Provider Details

I. General information

NPI: 1447055074
Provider Name (Legal Business Name): MICHAEL X SU MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2025
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

489 DEVON PARK DR STE 306
WAYNE PA
19087-1809
US

IV. Provider business mailing address

466 RIDGE LN
SPRINGFIELD PA
19064-1119
US

V. Phone/Fax

Practice location:
  • Phone: 610-663-4109
  • Fax:
Mailing address:
  • Phone: 318-918-0525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL X SU
Title or Position: CEO
Credential: MD, MA
Phone: 318-918-0525