Physician Compare National (NPI:1962551119)

HEALTHCARE PROVIDER: KENNETH ROGER SUSMAN M.D.

Physician Compare National contains general information about individual eligible professionals (EPs) such as demographic information and Medicare quality program participation.

Individual Professional Information
NPI	1962551119
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	5890953756
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20120223000091
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	SUSMAN
	Individual professional last name
Provider First Name	KENNETH
	Individual professional first name
Provider Middle Name	R
	Individual professional middle name
Provider Gender	M
	The provider's gender if the provider is a person.

Medical School Information
Medical School Name	UNIVERSITY OF CALIFORNIA, DAVIS SCHOOL OF MEDICINE
	Individual professional's medical school
Graduation Year	1988
	Individual professional's medical school graduation year
Primary Specialty	GENERAL SURGERY
	Primary medical specialty reported by the individual professional in the selected enrollment

Practice Information
Line 1 Street Address	700 RIVER DR
	Group Practice or individual's line 1 address
City	FORT BRAGG
	Group Practice or individual's city
State	CA
	Group Practice or individual's state
Zip Code	954375403
	Group Practice or individual's zip code (9 digits when available)
Phone Number	7079611234
	Phone number is listed only when there is a single phone number available for the practice location address

Hospital(s) Affiliation Information
Hospital Affiliation CCN 1	051325
	Medicare CCN of hospital where individual professional provides service 1
Hospital Affiliation LBN 1	MENDOCINO COAST DISTRICT HOSPITAL
	Legal business name of hospital where individual professional provides service 1
Professional Accepts Medicare Assignment	Y