Provider Demographics
NPI:1447336946
Name:NEILSEN, SUSAN A (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:NEILSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15900 SNOW RD
Mailing Address - Street 2:
Mailing Address - City:BROOKPARK
Mailing Address - State:OH
Mailing Address - Zip Code:44142-2859
Mailing Address - Country:US
Mailing Address - Phone:216-265-0772
Mailing Address - Fax:
Practice Address - Street 1:15900 SNOW RD
Practice Address - Street 2:
Practice Address - City:BROOKPARK
Practice Address - State:OH
Practice Address - Zip Code:44142-2859
Practice Address - Country:US
Practice Address - Phone:216-365-0772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35065003207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH378646OtherWELLCARE
OH340714684101OtherCARESOURCE
OH0969966Medicaid
OH196433OtherWELLCARE
OH341542312098OtherCARESOURCE
OH740117OtherBCHP
OHP00448233OtherRAILROAD CARE
OH000000370582OtherANTHEM BC/BS
OH000000380939OtherANTHEM BC/BS
OH740121OtherBCHP
OHP00368534OtherCARERR
OH196433OtherWELLCARE
OH340714684101OtherCARESOURCE
OHF78163Medicare UPIN