Provider Demographics
NPI:1568456309
Name:EGGL, SUSAN M (CRNA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:EGGL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4100 PARK FOREST DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7331
Mailing Address - Country:US
Mailing Address - Phone:231-935-5770
Mailing Address - Fax:231-935-0747
Practice Address - Street 1:4100 PARK FOREST DR
Practice Address - Street 2:SUITE 210
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7331
Practice Address - Country:US
Practice Address - Phone:231-935-5770
Practice Address - Fax:231-935-0747
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704124546367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1568456309Medicaid
MI430056904OtherMEDICARE RAIL ROAD TSC
MI430B810310OtherBCBS TSC
S92152Medicare UPIN
0B86029 014Medicare PIN