=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720083041
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSIE H KIM-MAULSBY M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2005
-----------------------------------------------------
Last Update Date | 01/28/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5400 KENNEDY AVE
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45213-2664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-281-3400
-----------------------------------------------------
Fax | 513-527-2275
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5400 KENNEDY AVE
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45213-2664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-281-3400
-----------------------------------------------------
Fax | 513-527-2275
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 35-078938
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------