Provider Demographics
NPI:1083634992
Name:ORTOLANO, SUSAN (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:ORTOLANO
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 1:1930 S BROAD ST
Mailing Address - Street 2:UNIT 5
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-2328
Mailing Address - Country:US
Mailing Address - Phone:215-567-5870
Mailing Address - Fax:215-467-5873
Practice Address - Street 1:1930 S BROAD ST
Practice Address - Street 2:UNIT 5
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-2328
Practice Address - Country:US
Practice Address - Phone:215-567-5870
Practice Address - Fax:215-467-5873
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-065232-L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001751871Medicaid
PAG91711Medicare UPIN
PA026685Medicare ID - Type Unspecified