MEDICARE: SUSAN A KEISNER MD

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	207Q00000X	Family Medicine Physician	C41820	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00C418200	OTHER	CA	MEDI CAL

General Provider Information

NPI Number	:	1417954793
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN A KEISNER MD

Provider Business Mailing Address
First Line	:	3401 W SUNFLOWER AVE.
Second Line	:	SUITE 250
City	:	SANTA ANA
State	:	CA
Zip	:	92704
Country	:	US
Telephone Number	:	714-619-8777
Fax Number	:	714-619-8770

Provider Business Practice Location Address
First Line	:	3401 W. SUNFLOWER AVE.
Second Line	:	SUITE 250
City	:	SANTA ANA
State	:	CA
Zip	:	92704
Country	:	US
Telephone Number	:	714-619-8777
Fax Number	:	714-619-8770

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

Provider Enumeration Date	:	07/01/2005
Last Update Date	:	05/07/2012

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