Basic Information
| Provider Information | |||||||||
| NPI: | 1487643037 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRALEY | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | E. | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636256 CENTRAL CREDENTIALING | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132453107 | ||||||||
| FaxNumber: | 5135855511 | ||||||||
| Practice Location | |||||||||
| Address1: | 234 GOODMAN ST | ||||||||
| Address2: | ML 0761 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452671000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135844391 | ||||||||
| FaxNumber: | 5135840431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2005 | ||||||||
| LastUpdateDate: | 02/12/2018 | ||||||||
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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 | 2085R0202X | 35-06-2155 | OH | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 200039480A | 05 | IN | MEDICAID | 0843798 | 05 | OH | MEDICAID | 64868219 | 05 | KY | MEDICAID | 1620954 | 01 | OH | UNITED HEALTHCARE | OTHER | 655258 | 01 | OH | AETNA | OTHER | 000000013880 | 01 | OH | ANTHEM | OTHER |