Provider Demographics
NPI:1629006929
Name:BRANDEL, SUSAN (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BRANDEL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22301 KELLY RD
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-2619
Mailing Address - Country:US
Mailing Address - Phone:586-443-5588
Mailing Address - Fax:
Practice Address - Street 1:22301 KELLY RD
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-2619
Practice Address - Country:US
Practice Address - Phone:586-443-5588
Practice Address - Fax:586-443-5538
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704120861363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E012730OtherBCBSM GROUP NUMBER
MI0865316OtherBCBS PIN NUMBER
MI1629006929Medicaid
MIN40180007Medicare PIN
MI0E012730OtherBCBSM GROUP NUMBER
P05796Medicare UPIN