Basic Information
| Provider Information | |||||||||
| NPI: | 1356362776 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIERSMA | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3605 WARRENSVILLE CENTER RD | ||||||||
| Address2: | |||||||||
| City: | SHAKER HTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162866299 | ||||||||
| FaxNumber: | 2162866341 | ||||||||
| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441061716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168447700 | ||||||||
| FaxNumber: | 2162866341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 10/01/2008 | ||||||||
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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 | 2080P0207X | 35-051050 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology |
ID Information
| ID | Type | State | Issuer | Description | 742534 | 01 | OH | BUCKEYE | OTHER | 200206560A | 01 | OK | OK MEDICAID | OTHER | 2056126 | 05 | OH | MEDICAID | 364131 | 01 | OH | WELLCARE | OTHER | 000000221140 | 01 | OH | UNISON | OTHER | 000000027183 | 01 | OH | ANTHEM | OTHER | 000000526169 | 01 | OH | ANTHEM | OTHER | 2056126 | 01 | OH | BCMH | OTHER | 2093513 | 01 | OH | AETNA | OTHER |