Basic Information
| Provider Information | |||||||||
| NPI: | 1790709947 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STAGNO | ||||||||
| FirstName: | SUSAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20800 HARVARD ROAD | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | HIGHLAND HILLS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162866260 | ||||||||
| FaxNumber: | 2162866341 | ||||||||
| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168442400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 01/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 35048038S | OH | N | Other Service Providers | Specialist | 2084P0015X | 35-048038 | OH | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychosomatic Medicine | 2084P0800X | 35-04-8038 | OH | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 35048038S | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 0594192 | 05 | OH | MEDICAID | P00469476 | 01 | MEDICARE RAILROAD | OTHER | 000000365167 | 01 | OH | ANTHEM | OTHER |