Provider Demographics
NPI:1598767394
Name:VANDELLEN, SUSAN J (DO)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:VANDELLEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 RIVER CENTRE DR
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-4463
Mailing Address - Country:US
Mailing Address - Phone:810-985-4900
Mailing Address - Fax:810-985-3634
Practice Address - Street 1:940 RIVER CENTRE DR
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-4463
Practice Address - Country:US
Practice Address - Phone:810-985-4900
Practice Address - Fax:810-985-3634
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009277207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4610438Medicaid
MI4610438Medicaid
MI0G46008009Medicare ID - Type UnspecifiedMEDICARE