=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811240989
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHELLEY SUSMAN, M.D., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2012
-----------------------------------------------------
Last Update Date | 10/26/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18370 BURBANK BLVD SUITE 100
-----------------------------------------------------
City | TARZANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91356-2804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-757-2222
-----------------------------------------------------
Fax | 818-881-7973
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10445 WILSHIRE BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90024-4634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-471-4568
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | DR. SHELLEY SUSMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 818-757-2222
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | C41775
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------