Provider Demographics
NPI:1538258983
Name:SUSLOW-GEDITZ, ALEXANDRA
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:SUSLOW-GEDITZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5310 S 84TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68127-3775
Mailing Address - Country:US
Mailing Address - Phone:402-827-6510
Mailing Address - Fax:
Practice Address - Street 1:5310 S 84TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68127-3775
Practice Address - Country:US
Practice Address - Phone:402-827-6510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE21902207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEH46530Medicare UPIN