Basic Information
| Provider Information | |||||||||
| NPI: | 1225005457 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLORES | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GUMABAO-FLORES | ||||||||
| OtherFirstName: | SUSAN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 20525 CENTER RIDGE RD | ||||||||
| Address2: | STE 220 | ||||||||
| City: | ROCKY RIVER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408955056 | ||||||||
| FaxNumber: | 4403332935 | ||||||||
| Practice Location | |||||||||
| Address1: | 1730 W 25TH ST | ||||||||
| Address2: | MAIN FLOOR | ||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2163632353 | ||||||||
| FaxNumber: | 2166967375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 05/27/2008 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35044831F | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 10792405 | 01 | CAQH | OTHER | 3610861 | 01 | GROUP ASC MEDICARE | OTHER | 000000184291 | 01 | ANTHEM | OTHER | 0119204 | 01 | GROUP MEDICAID | OTHER | 0637236 | 01 | AETNA | OTHER | 0799711 | 05 | OH | MEDICAID | 110213695 | 01 | RR MEDICARE INDIVIDUAL | OTHER | 9273172 | 01 | GROUP MEDICARE | OTHER | F44831 | 01 | SUMMACARE APEX | OTHER | 102422 | 01 | KAISER | OTHER | 1780634279 | 01 | GROUP NPI | OTHER | D368301 | 01 | GROUP IND DIAGNOSTICS MED | OTHER | 341783789066 | 01 | CARESOURCE | OTHER | CA4511 | 01 | RR GROUP MEDICARE | OTHER | CA4511 | 01 | RR MEDICARE GROUP | OTHER |