Individual
SUSAN C NICOLSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
34TH STREET & CIVIC CENTER BLVD, SUITE 9329, PHILADELPHIA, PA 19104-4399
(215) 590-1867
(215) 590-5824
Mailing address
100 E PENN SQ, THE WANAMAKER BUILDING, 9TH FLOOR, PHILADELPHIA, PA 19107-3323
(297) 425-9300
(297) 425-9331
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
MD024170E
PA
207LP2900X
Pain Medicine (Anesthesiology) Physician
MD024170E
PA
207LP3000X
Pediatric Anesthesiology Physician
Primary
MD024170E
PA
208000000X
Pediatrics Physician
MD024170E
PA
2080P0203X
Pediatric Critical Care Medicine Physician
MD024170E
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0009928990
—
PA
01
—
097501EMD
MEDICARE PTAN CCM
PA
01
—
097501J6Z
MEDICARE PTAN PAIN MANAGEMENT
PA
01
—
181300EJL
MEDICARE PTAN
PA
Enumeration date
08/15/2006
Last updated
04/11/2013
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