Provider Demographics
NPI:1720025042
Name:HENRY, SUSAN K (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:K
Last Name:HENRY
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 1:6050 N US HIGHWAY 31
Mailing Address - Street 2:
Mailing Address - City:FREE SOIL
Mailing Address - State:MI
Mailing Address - Zip Code:49411-9157
Mailing Address - Country:US
Mailing Address - Phone:231-757-1260
Mailing Address - Fax:231-757-1261
Practice Address - Street 1:6050 N US HIGHWAY 31
Practice Address - Street 2:
Practice Address - City:FREE SOIL
Practice Address - State:MI
Practice Address - Zip Code:49411-9157
Practice Address - Country:US
Practice Address - Phone:231-757-1260
Practice Address - Fax:231-757-1261
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301042734207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICJ9804OtherRAILROAD MEDICARE GBA PIN
MI383322171OtherTAX ID
MI4375777Medicaid
MI0530023OtherBLUE CROSS BLUE SHIELD
MI0N29840Medicare PIN
MI383322171OtherTAX ID