Basic Information
| Provider Information | |||||||||
| NPI: | 1053317743 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NORTHCUTT | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | N. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ESCUDIER | ||||||||
| OtherFirstName: | SUZANNE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 27476 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841270476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067432898 | ||||||||
| FaxNumber: | 8067432787 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 4TH ST | ||||||||
| Address2: | STE 1C282 | ||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794308182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067432981 | ||||||||
| FaxNumber: | 8067432984 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2005 | ||||||||
| LastUpdateDate: | 12/09/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | L0154 | TX | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 106163201 | 05 | TX | MEDICAID | 112357100 | 01 | TX | FIRSTCARE COMMERCIAL | OTHER | 84337Z | 01 | TX | HMO BLUE | OTHER | 100159300A | 05 | OK | MEDICAID | 106163202 | 05 | TX | MEDICAID | 69256 | 05 | NM | MEDICAID | A401 | 01 | TRIWEST | OTHER | 69256 | 01 | NM | PRESBYTERIAN COMMERCIAL | OTHER | 82631X | 01 | TX | BLUE CROSS & BLUE SHIELD | OTHER | 112357102 | 05 | TX | MEDICAID | G0808 | 05 | NM | MEDICAID |