Provider Demographics
NPI:1568441046
Name:KINNISON, SUSAN (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:KINNISON
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 1:213 S JEFFERSON ST STE 625
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5679
Mailing Address - Fax:
Practice Address - Street 1:101 ELM AVE SE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24013-2222
Practice Address - Country:US
Practice Address - Phone:540-224-4325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101227973207Q00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007313535Medicaid
VAP00310524OtherMEDICARE RAILROAD
VA1568441046Medicaid
VAP00310524OtherMEDICARE RAILROAD
VA00W716L42Medicare ID - Type UnspecifiedRICHMOND MEDICARE
VA1568441046Medicaid
VAVV1205BMedicare PIN