Provider Demographics
NPI:1447055074
Name:MICHAEL X SU MD PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:MICHAEL X SU MD PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:X
Authorized Official - Last Name:SU
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MA
Authorized Official - Phone:318-918-0525
Mailing Address - Street 1:466 RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:19064-1119
Mailing Address - Country:US
Mailing Address - Phone:318-918-0525
Mailing Address - Fax:
Practice Address - Street 1:489 DEVON PARK DR STE 306
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-1809
Practice Address - Country:US
Practice Address - Phone:610-663-4109
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-18
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health