Basic Information
| Provider Information | |||||||||
| NPI: | 1437168200 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TRAVIS | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 N 20TH ST | ||||||||
| Address2: | CHCA SUITE 301 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191031443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155672422 | ||||||||
| FaxNumber: | 2155610959 | ||||||||
| Practice Location | |||||||||
| Address1: | 1012 LAUREL OAK RD | ||||||||
| Address2: | SPECIALTY CENTER AT VOORHEES | ||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080433505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564357502 | ||||||||
| FaxNumber: | 2155610959 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | MD014051E | PA | X | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 25MA03289400 | NJ | X | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0207X | MD014051E | PA | X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology | 2080P0207X | 25MA03289400 | NJ | X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology |
ID Information
| ID | Type | State | Issuer | Description | 0527203 | 05 | NJ | MEDICAID |