Basic Information
| Provider Information | |||||||||
| NPI: | 1841276946 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KETCHEM | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 900 | ||||||||
| Address2: | |||||||||
| City: | PHILIPPI | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044572800 | ||||||||
| FaxNumber: | 3044574011 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 HEALTHCARE DR | ||||||||
| Address2: | |||||||||
| City: | PHILIPPI | ||||||||
| State: | WV | ||||||||
| PostalCode: | 264169406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044572800 | ||||||||
| FaxNumber: | 3044574011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2005 | ||||||||
| LastUpdateDate: | 08/24/2011 | ||||||||
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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 | 363AM0700X | 01397 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1841276946 | 01 | WV | MT STATE BC/BS | OTHER | 3810000464 | 05 | WV | MEDICAID | MK0702248 | 01 | WV | DEA | OTHER | WV01397 | 01 | WV | THE HEALTH PLAN | OTHER |