Provider Demographics
NPI:1255439097
Name:RIEGG, SUSAN J (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:RIEGG
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 1:11697 N CANTERBURY DRIVE
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092
Mailing Address - Country:US
Mailing Address - Phone:262-242-8997
Mailing Address - Fax:
Practice Address - Street 1:13111 N PORT WASHINGTON ROAD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53097
Practice Address - Country:US
Practice Address - Phone:262-243-7471
Practice Address - Fax:262-243-7407
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33675207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32106200Medicaid
G00679Medicare UPIN