Provider Demographics
NPI:1538197348
Name:PROBST, SUSAN J (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:PROBST
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 1:740 PENN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST READING
Mailing Address - State:PA
Mailing Address - Zip Code:19611-1006
Mailing Address - Country:US
Mailing Address - Phone:610-376-3700
Mailing Address - Fax:610-685-1567
Practice Address - Street 1:740 PENN AVE
Practice Address - Street 2:
Practice Address - City:WEST READING
Practice Address - State:PA
Practice Address - Zip Code:19611-1006
Practice Address - Country:US
Practice Address - Phone:610-376-3700
Practice Address - Fax:610-685-1567
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038524L207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMD038524LOtherSTATE LICENSE
TAX IDOther23-2991405
PAC27809Medicare UPIN
PA025498Medicare ID - Type UnspecifiedMEDICARE