Basic Information
| Provider Information | |||||||||
| NPI: | 1063501542 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SU | ||||||||
| FirstName: | RUMIE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 393 E WALNUT ST | ||||||||
| Address2: | 3RD FLOOR SE PHR SYSTEM | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911880001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264057914 | ||||||||
| FaxNumber: | 6264056768 | ||||||||
| Practice Location | |||||||||
| Address1: | 25965 NORMANDIE AVE | ||||||||
| Address2: | |||||||||
| City: | HARBOR CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907103416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102575179 | ||||||||
| FaxNumber: | 3105174520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | A51099 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 00A510990 | 05 | CA | MEDICAID |