Basic Information
Provider Information | |||||||||
NPI: | 1669587747 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RAPHAELY | ||||||||
FirstName: | SUSAN | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 24701 EUCLID AVE | ||||||||
Address2: | 3RD FLOOR | ||||||||
City: | EUCLID | ||||||||
State: | OH | ||||||||
PostalCode: | 441171714 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2163836616 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 11100 EUCLID AVE | ||||||||
Address2: |   | ||||||||
City: | CLEVELAND | ||||||||
State: | OH | ||||||||
PostalCode: | 441061716 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2168447330 | ||||||||
FaxNumber: | 2168443781 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/20/2006 | ||||||||
LastUpdateDate: | 08/19/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 35-066167 | OH | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207LA0401X | 35-066167 | OH | N |   | Allopathic & Osteopathic Physicians | Anesthesiology | Addiction Medicine | 207LC0200X | 35-066167 | OH | N |   | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine | 207LH0002X | 35-066167 | OH | N |   | Allopathic & Osteopathic Physicians | Anesthesiology | Hospice and Palliative Medicine | 207LP2900X | 35-066167 | OH | N |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207LP3000X | 35-066167 | OH | N |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology |
ID Information
ID | Type | State | Issuer | Description | 0583328 | 01 | OH | BCMH | OTHER | 000000516056 | 01 | OH | ANTHEM | OTHER | 5229680 | 01 | OH | AETNA | OTHER | 000000221133 | 01 | OH | UNISON | OTHER | 2042284 | 05 | OH |   | MEDICAID | 744154 | 01 | OH | BUCKEYE MEDICAID | OTHER | P00077454 | 01 | OH | RAILROAD MEDICARE | OTHER | 363936 | 01 | OH | WELLCARE MEDICAID | OTHER | P00385140 | 01 | OH | MEDICARE RAILROAD | OTHER |