Provider Demographics
NPI:1922087790
Name:MILJKOVIC-GOODRICH, SUSAN MICHELLE (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MICHELLE
Last Name:MILJKOVIC-GOODRICH
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 1:970 E WASHINGTON ST
Mailing Address - Street 2:SUITE 6-C
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-3332
Mailing Address - Country:US
Mailing Address - Phone:330-722-3083
Mailing Address - Fax:330-725-5043
Practice Address - Street 1:970 E WASHINGTON ST
Practice Address - Street 2:SUITE 6-C
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-3332
Practice Address - Country:US
Practice Address - Phone:330-722-3083
Practice Address - Fax:330-725-5043
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-082575M246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2500163Medicaid
OH4117362Medicare ID - Type Unspecified
OH2500163Medicaid
OHH94855Medicare UPIN