MEDICARE: DR. SUSAN STANTON DOUGLAS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	MD429498	PA
2	2084P0804X	Child & Adolescent Psychiatry Physician	MD429498	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043411341
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN STANTON DOUGLAS M.D.

Provider Business Mailing Address
First Line	:	2 EASTGATE AVE
Second Line	:
City	:	MONESSEN
State	:	PA
Zip	:	15062-1393
Country	:	US
Telephone Number	:	724-684-6489
Fax Number	:	724-684-7116

Provider Business Practice Location Address
First Line	:	2 EASTGATE AVE
Second Line	:
City	:	MONESSEN
State	:	PA
Zip	:	15062-1393
Country	:	US
Telephone Number	:	724-684-6489
Fax Number	:	724-684-7116

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2007
Last Update Date	:	03/18/2016

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