Provider Demographics
NPI:1124054465
Name:ROTH, SUSAN B (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:B
Last Name:ROTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:B
Other - Last Name:OREL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3400 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104
Mailing Address - Country:US
Mailing Address - Phone:215-662-3005
Mailing Address - Fax:215-662-7011
Practice Address - Street 1:3400 SPRUCE ST
Practice Address - Street 2:GROUND FLOOR DULLES
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-662-3005
Practice Address - Fax:215-662-7011
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-00130612085R0202X
PAMD045361E2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012252390001Medicaid
PA0012252390001Medicaid
PA636524Medicare PIN