Provider Demographics
NPI:1700912003
Name:HANEY, SUSAN THERESA (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:THERESA
Last Name:HANEY
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 1:2670 BROADWAY AVE
Mailing Address - Street 2:PMB 17
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2400 LANCASTER DR NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1221
Practice Address - Country:US
Practice Address - Phone:503-813-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052948207P00000X
ORMD23325207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR275193Medicaid
OR0000ZGBJDOtherGROUP MEDICARE #
OR1225016561OtherGROUP NPI #
OR0000ZGBJDOtherGROUP MEDICARE #
OR1225016561OtherGROUP NPI #