Provider Demographics
NPI:1134198203
Name:ALLEN, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 TOWN CENTER DR
Mailing Address - Street 2:STE 203
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-1744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1949 W 12 MILE RD STE 100
Practice Address - Street 2:BEAUMONT GERIATRIC SERVICES
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-1868
Practice Address - Country:US
Practice Address - Phone:248-551-1756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301065763207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4266950Medicaid
MI0F349850OtherBCBSM
MI4266950Medicaid
MI0F349850OtherBCBSM