Basic Information
| Provider Information | |||||||||
| NPI: | 1134104375 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | SCHRIMPF | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SCHRIMP | ||||||||
| OtherFirstName: | SUSAN | ||||||||
| OtherMiddleName: | URSULA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 636256 | ||||||||
| Address2: | CENTRAL CREDENTIALING | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135855502 | ||||||||
| FaxNumber: | 5135855511 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 CRESCENT AVE | ||||||||
| Address2: | UNIVERSITY WYOMING FAMILY PRACTICE CENTER | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452154406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138210275 | ||||||||
| FaxNumber: | 5138213621 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2005 | ||||||||
| LastUpdateDate: | 06/13/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | 34-006680 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2158801 | 05 | OH | MEDICAID |