=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194031195
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THOMAS SUSKO M.D., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2010
-----------------------------------------------------
Last Update Date | 02/21/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2021 SANTA MONICA BLVD SUITE 200E
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90404-2208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-829-5557
-----------------------------------------------------
Fax | 310-829-5554
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2021 SANTA MONICA BLVD SUITE 200E
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90404-2208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-829-5557
-----------------------------------------------------
Fax | 310-829-5554
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. THOMAS MICHAEL SUSKO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 310-829-5557
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | 118282
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------