Provider Demographics
NPI:1598728636
Name:RUTHERFORD, SUSAN OWEN (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:OWEN
Last Name:RUTHERFORD
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:OWEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3333 EVERGREEN DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9493
Mailing Address - Country:US
Mailing Address - Phone:616-364-4200
Mailing Address - Fax:616-364-7347
Practice Address - Street 1:3333 EVERGREEN DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9493
Practice Address - Country:US
Practice Address - Phone:616-364-4200
Practice Address - Fax:616-364-7347
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704207135367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104349131Medicaid
MI430D110990OtherBCBS GROUP BILL PIN
MICE1952OtherRAILROAD GROUP
MI0875931OtherBCBS PIN
MI430044534OtherRAILROAD MEDICARE
MISR207135OtherBCBS LICENSE
MI0875931OtherBCBS PIN
MI104349131Medicaid