MEDICARE: DR. SUSAN A NASRI M.D.

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician	01052481	IN

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	050087310	OTHER	IN	RAILROAD MEDICARE

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	163856	OTHER	IN	CSHCS
4	163855	OTHER	IN	CSHCS
5	163857	OTHER	IN	CSHCS

NPI Number	:	1457359598
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN A NASRI M.D.

Provider Business Mailing Address
First Line	:	2914 S REPUBLIC BLVD
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43615-1912
Country	:	US
Telephone Number	:	419-531-8808
Fax Number	:	419-531-9342

Provider Business Practice Location Address
First Line	:	5734 COVENTRY LN
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-7141
Country	:	US
Telephone Number	:	260-436-7875
Fax Number	:	260-432-9812

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

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	11/20/2014

5734 COVENTRY LANE
FORT WAYNE, IN
46804-7141

Practice Phone: 260-436-7875
Practice Fax: 260-432-9812

5734 COVENTRY LN
FORT WAYNE, IN
46804-7141