Provider Demographics
NPI:1982674669
Name:SMITH, SUSAN J (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S BALLENGER HWY
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3638
Mailing Address - Country:US
Mailing Address - Phone:810-342-1000
Mailing Address - Fax:810-342-1590
Practice Address - Street 1:401 S BALLENGER HWY
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3638
Practice Address - Country:US
Practice Address - Phone:810-342-1000
Practice Address - Fax:810-342-1590
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044626207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB45557OtherHEALTH NET FEDERAL SERVIC
MI1101091OtherHEALTH PLUS
MI2693558Medicaid
MI4685822Medicaid
MI110B56125OtherCOMMUNITY BLUE PPO
MIB45557OtherHAP
MI1112501091OtherBLUE CROSS BLUE SHIELD
MI110B56125OtherBLUE CROSS BLUE SHIELD
MI110B56125OtherCOMMUNITY BLUE PPO
MI2693558Medicaid