Provider Demographics
NPI:1891704599
Name:FABRICK, SUSAN CAROL (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:CAROL
Last Name:FABRICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2700 BAKER ST FL 3
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-2157
Mailing Address - Country:US
Mailing Address - Phone:231-737-1335
Mailing Address - Fax:231-737-0534
Practice Address - Street 1:2700 BAKER ST FL 3
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-2157
Practice Address - Country:US
Practice Address - Phone:231-737-1335
Practice Address - Fax:231-737-0534
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301064116207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4748904OtherMEDICAID
MI0806110231OtherBCBSM
MI4748904OtherMEDICAID
MION79590001Medicare ID - Type Unspecified