MEDICARE: SUSANNA G. EVANS 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	MD417655	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8649657	OTHER	PA	CIGNA HMO/PPO
2	2105709000	OTHER	PA	IBC - PC/KHPE
3	1163241	OTHER	PA	KEYSTONE MERCY
4	17713-MD417655	OTHER	PA	HEALTH PARTNERS
5	2105709000	OTHER	PA	AMERIHEALTH/INTERCOUNTY
6	10926381	OTHER	PA	CAQH ID#
7	080191559	OTHER	PA	RRM
8	1419348	OTHER	PA	HIGHMARK BLUE SHIELD
9	4641104	OTHER	PA	AETNA PPO
10	0189959402	OTHER	PA	AMERICHOICE (UHC MA PLAN)
11	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
12	2999717	OTHER	PA	AETNA HMO

General Provider Information

NPI Number	:	1770523870
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSANNA G. EVANS MD

Provider Business Mailing Address
First Line	:	1601 CHERRY ST
Second Line	:	SUITE 11511
City	:	PHILADELPHIA
State	:	PA
Zip	:	19102-1321
Country	:	US
Telephone Number	:	215-255-7822
Fax Number	:

Provider Business Practice Location Address
First Line	:	10 SHURS LN
Second Line	:	SUITE 409
City	:	PHILADELPHIA
State	:	PA
Zip	:	19127-2123
Country	:	US
Telephone Number	:	215-482-1234
Fax Number	:	215-482-0465

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

Provider Enumeration Date	:	06/07/2006
Last Update Date	:	08/30/2016

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