1821256116 NPI number — SUSAN A. RADTKE, M.D., P.C.

Table of content: (NPI 1821256116)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821256116 NPI number — SUSAN A. RADTKE, M.D., P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUSAN A. RADTKE, 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:
1821256116
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21321 HARPER AVE
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
SAINT CLAIR SHORES
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48080-2243
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-776-0797
Provider Business Mailing Address Fax Number:
586-776-4910

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21321 HARPER AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
SAINT CLAIR SHORES
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48080-2243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-776-0797
Provider Business Practice Location Address Fax Number:
586-776-4910
Provider Enumeration Date:
05/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
RADTKE
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
ANNE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
586-776-0797

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0500301 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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