Healthcare Provider Details

I. General information

NPI: 1912054719
Provider Name (Legal Business Name): SUSAN FOWLER GUELICH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN M FOWLER M.D.

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4348 ELECTRIC RD
ROANOKE VA
24018-0720
US

IV. Provider business mailing address

213 S JEFFERSON ST STE 1006 STE 1006
ROANOKE VA
24011-1713
US

V. Phone/Fax

Practice location:
  • Phone: 540-769-0976
  • Fax: 540-985-0912
Mailing address:
  • Phone: 540-224-5516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number2009-01001
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number0101249088
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2009-01001
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101249088
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: