Provider Demographics
NPI:1396813754
Name:MCCREADIE, SUSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:MCCREADIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:ELAINE
Other - Last Name:GUNDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2350 WASHTENAW AVE
Mailing Address - Street 2:STE 24
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-4532
Mailing Address - Country:US
Mailing Address - Phone:734-213-0255
Mailing Address - Fax:734-213-0241
Practice Address - Street 1:2350 WASHTENAW AVE
Practice Address - Street 2:STE 24
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-4532
Practice Address - Country:US
Practice Address - Phone:734-213-0255
Practice Address - Fax:734-213-0241
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301072258208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3506345401OtherBLUE CROSS BLUE SHIELD