Basic Information
| Provider Information | |||||||||
| NPI: | 1215981840 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANIC | ||||||||
| FirstName: | SUZANA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | PROF. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 551420 | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333551420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002433839 | ||||||||
| FaxNumber: | 9548392569 | ||||||||
| Practice Location | |||||||||
| Address1: | 2701 N. DECATUR RD | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300330000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6785141991 | ||||||||
| FaxNumber: | 6785141992 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 04/10/2013 | ||||||||
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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 | 207L00000X | 046030 | GA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 000974179A | 05 | GA | MEDICAID |