=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639435654
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN MARIE EISENMANN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2012
-----------------------------------------------------
Last Update Date | 04/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 380 SUMMIT AVE
-----------------------------------------------------
City | STEUBENVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43952-2667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-283-7529
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14968 SPRUCEVALE RD
-----------------------------------------------------
City | EAST LIVERPOOL
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43920-9020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | PTA07986
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------