Provider Demographics
NPI:1891903480
Name:TERRELL, SUSAN MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARIE
Last Name:TERRELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:SCANLON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:245 STATE ST SE
Mailing Address - Street 2:STE 1A
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:616-685-8050
Mailing Address - Fax:616-454-0740
Practice Address - Street 1:200 JEFFERSON SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-685-5231
Practice Address - Fax:616-685-5260
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301078344207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3233040Medicare PIN