1720290943 NPI number — KATHRYN H. SUSSMAN, M.D. P.C.

Table of content: (NPI 1720290943)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720290943 NPI number — KATHRYN H. SUSSMAN, M.D. P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KATHRYN H. SUSSMAN, M.D. P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720290943
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28800 RYAN RD
Provider Second Line Business Mailing Address:
SUITE 320
Provider Business Mailing Address City Name:
WARREN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48092-4272
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-573-4980
Provider Business Mailing Address Fax Number:
586-573-0640

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28800 RYAN RD
Provider Second Line Business Practice Location Address:
SUITE 320
Provider Business Practice Location Address City Name:
WARREN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48092-4272
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-573-4980
Provider Business Practice Location Address Fax Number:
586-573-0640
Provider Enumeration Date:
05/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SUSSMAN
Authorized Official First Name:
KATHRYN
Authorized Official Middle Name:
H
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
586-573-4980

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: KS050808 . This is a "BLUECROSSBLUESHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0705037252 . This is a "BLUECROSSBLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0E06271 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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