Provider Demographics
NPI:1306802889
Name:YELICH, SUSAN M (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:YELICH
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:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-578-5880
Mailing Address - Fax:859-578-5881
Practice Address - Street 1:85 N GRAND AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:FORT THOMAS
Practice Address - State:KY
Practice Address - Zip Code:41075
Practice Address - Country:US
Practice Address - Phone:859-781-2628
Practice Address - Fax:859-572-4403
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY37671208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64056708Medicaid
OH2549451Medicaid
P00700408Medicare PIN
KY0957605Medicare PIN
KY0957505Medicare PIN
KY64056708Medicaid
KY0364989Medicare PIN
OH2549451Medicaid