Healthcare Provider Details

I. General information

NPI: 1679761498
Provider Name (Legal Business Name): SUZANNE CATHERINE CRANDALL D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2007
Last Update Date: 08/05/2021
Certification Date: 08/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 MORRIS ST STE 300
CHARLESTON WV
25301-1853
US

IV. Provider business mailing address

415 MORRIS ST STE 300
CHARLESTON WV
25301-1853
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-6441
  • Fax: 304-388-6445
Mailing address:
  • Phone: 304-388-6441
  • Fax: 304-388-6445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2009007653
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number5101016555
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number3679
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: