Provider Demographics
NPI:1821256116
Name:SUSAN A. RADTKE, M.D., P.C.
Entity Type:Organization
Organization Name:SUSAN A. RADTKE, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:RADTKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-776-0797
Mailing Address - Street 1:21321 HARPER AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2243
Mailing Address - Country:US
Mailing Address - Phone:586-776-0797
Mailing Address - Fax:586-776-4910
Practice Address - Street 1:21321 HARPER AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2243
Practice Address - Country:US
Practice Address - Phone:586-776-0797
Practice Address - Fax:586-776-4910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-23
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0500301OtherBCBS
0500301OtherBCBS
A76146Medicare UPIN