Provider Demographics
NPI:1265422653
Name:VANDENBOSCH, SUSAN L (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:VANDENBOSCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:221 MICHIGAN ST NE
Practice Address - Street 2:SUITE 600
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2543
Practice Address - Country:US
Practice Address - Phone:616-774-7035
Practice Address - Fax:616-774-4057
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MISV063766174400000X
MI4301063766207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3476176Medicaid
MIG81118Medicare UPIN