Provider Demographics
NPI:1164753950
Name:WAITE, SUSAN MARIE (NBC-HIS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:WAITE
Suffix:
Gender:F
Credentials:NBC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2404 WILDWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-3927
Mailing Address - Country:US
Mailing Address - Phone:517-788-7677
Mailing Address - Fax:517-788-7679
Practice Address - Street 1:2404 WILDWOOD AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-3927
Practice Address - Country:US
Practice Address - Phone:517-788-7677
Practice Address - Fax:517-788-7679
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-19
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3501002419332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332S00000XSuppliersHearing Aid Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540C802820OtherBLUE CROSS AND BLUE SHIELD OF MICHIGAN
MI905258069Medicaid