Provider Demographics
NPI:1588659510
Name:EMMICK, SUSAN M (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:EMMICK
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 1:1100 SOUTHFIELD DR
Mailing Address - Street 2:SUITE 1370
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-4498
Mailing Address - Country:US
Mailing Address - Phone:317-837-5571
Mailing Address - Fax:317-837-5580
Practice Address - Street 1:8244 E US HIGHWAY 36
Practice Address - Street 2:SUITE 210
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-9575
Practice Address - Country:US
Practice Address - Phone:317-272-7337
Practice Address - Fax:317-272-8534
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01041466A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200036220AMedicaid
ING03212Medicare UPIN
IN200036220AMedicaid