Provider Demographics
NPI:1023294584
Name:SUSAN MITHOFF QUADE OD PC
Entity type:Organization
Organization Name:SUSAN MITHOFF QUADE OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:QUADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-676-4500
Mailing Address - Street 1:2299 WEST RD
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-3615
Mailing Address - Country:US
Mailing Address - Phone:734-676-4500
Mailing Address - Fax:734-676-1587
Practice Address - Street 1:2299 WEST RD
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-3615
Practice Address - Country:US
Practice Address - Phone:734-676-4500
Practice Address - Fax:734-676-1587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-15
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003686332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900H22910OtherBLUE CROSS
MI0N86570Medicare PIN
MI900H22910OtherBLUE CROSS
MIDO1832Medicare PIN