Provider Demographics
NPI:1528019155
Name:JURASEK, SUSAN (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:JURASEK
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 1:19020 FORT ST
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48193-6701
Mailing Address - Country:US
Mailing Address - Phone:734-362-5100
Mailing Address - Fax:734-362-5147
Practice Address - Street 1:19020 FORT ST
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:MI
Practice Address - Zip Code:48193-6701
Practice Address - Country:US
Practice Address - Phone:734-362-5100
Practice Address - Fax:734-362-5147
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076380207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI16362OtherMCARE
MI4621100Medicaid
MI4301076380OtherPHYSICIAN LICENSE
MI2366034OtherUHC
MI136932OtherMERCY CARE CHOICES
MICC3713OtherRR MEDICARE
MI6675152OtherCIGNA
MI700H21076OtherBCBSM
MI7160529OtherAETNA
MICC3713OtherRR MEDICARE
MICC3713OtherRR MEDICARE
MI136932OtherMERCY CARE CHOICES