Provider Demographics
NPI:1558804674
Name:SUSAN L DRUST NP PLLC
Entity Type:Organization
Organization Name:SUSAN L DRUST NP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:NYBLADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-740-0914
Mailing Address - Street 1:296 SEMINOLE RD
Mailing Address - Street 2:
Mailing Address - City:NORTON SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:49444-3733
Mailing Address - Country:US
Mailing Address - Phone:231-375-5251
Mailing Address - Fax:231-375-8439
Practice Address - Street 1:296 SEMINOLE RD
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49444-3733
Practice Address - Country:US
Practice Address - Phone:231-740-0914
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-21
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704168366261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIS64229Medicare UPIN