Provider Demographics
NPI:1164488870
Name:BARNES, SUSAN S (DO)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:S
Last Name:BARNES
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 BOW POINTE DR STE 315
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-5402
Mailing Address - Country:US
Mailing Address - Phone:248-625-4000
Mailing Address - Fax:248-625-2622
Practice Address - Street 1:6815 DIXIE HWY STE 1
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-2092
Practice Address - Country:US
Practice Address - Phone:248-384-8360
Practice Address - Fax:248-384-8360
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011977208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4510933Medicaid
0M61910Medicare ID - Type Unspecified
MI4510933Medicaid