Provider Demographics
NPI:1336121680
Name:CHAMBERLAIN, SUSAN B (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:B
Last Name:CHAMBERLAIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2363 W JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-2705
Mailing Address - Country:US
Mailing Address - Phone:734-676-2800
Mailing Address - Fax:734-676-4418
Practice Address - Street 1:2363 W JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-2705
Practice Address - Country:US
Practice Address - Phone:734-676-2800
Practice Address - Fax:734-676-4418
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301407053208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
P18100001Medicare ID - Type Unspecified
F14375Medicare UPIN