=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538177316
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN MELLER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2006
-----------------------------------------------------
Last Update Date | 10/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2300 W SAHARA AVE STE 800
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89102-4397
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-666-8145
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 415 CHAPEL RD
-----------------------------------------------------
City | ELKINS PARK
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19027-2504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-287-0412
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | OS012125
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | T4557
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 17892
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 91285
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 25MB11418600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 02006612A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | OS012125
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | DO3045
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | OS18229
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------