Provider Demographics
NPI:1104818871
Name:SUSQUEHANNA OB-GYN LLC
Entity type:Organization
Organization Name:SUSQUEHANNA OB-GYN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DODSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-398-0189
Mailing Address - Street 1:520 UPPER CHESAPEAKE DR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-4339
Mailing Address - Country:US
Mailing Address - Phone:443-643-4300
Mailing Address - Fax:443-643-4303
Practice Address - Street 1:520 UPPER CHESAPEAKE DR
Practice Address - Street 2:SUITE 301
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4339
Practice Address - Country:US
Practice Address - Phone:410-939-3121
Practice Address - Fax:443-643-4303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-18
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0033079174400000X
207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKQ13OtherMEDICARE GROUP ID
MD499251202Medicaid
MD232921200Medicaid
MD232921200Medicaid