Provider Demographics
NPI:1770621344
Name:BAUM, SUSAN GAIL (REGISTERED DIETITIAN)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:GAIL
Last Name:BAUM
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15505 VINE COTTAGE DR
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20120-3750
Mailing Address - Country:US
Mailing Address - Phone:703-999-6290
Mailing Address - Fax:
Practice Address - Street 1:13135 LEE JACKSON MEMORIAL HWY
Practice Address - Street 2:STE 201
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1907
Practice Address - Country:US
Practice Address - Phone:703-999-6290
Practice Address - Fax:703-241-7723
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-03
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4624075OtherAETNA PROVIDER ID
VA492111Medicare ID - Type Unspecified