Provider Demographics
NPI:1568476216
Name:EISENMENGER, SUSAN M (DC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:EISENMENGER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:RED WING
Mailing Address - State:MN
Mailing Address - Zip Code:55066-2524
Mailing Address - Country:US
Mailing Address - Phone:651-388-0097
Mailing Address - Fax:
Practice Address - Street 1:424 W 5TH ST
Practice Address - Street 2:
Practice Address - City:RED WING
Practice Address - State:MN
Practice Address - Zip Code:55066-2524
Practice Address - Country:US
Practice Address - Phone:651-388-0097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3040111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN43G75EIOtherBLUE CROSS BLUE SHIELD
MN6343139-00Medicaid
MN350002390Medicare ID - Type Unspecified