Provider Demographics
NPI:1396826418
Name:CHARLAMB, SUSAN DALE (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:DALE
Last Name:CHARLAMB
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 1:5600 W MAPLE RD
Mailing Address - Street 2:SUITE C-304
Mailing Address - City:W BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3704
Mailing Address - Country:US
Mailing Address - Phone:248-855-5540
Mailing Address - Fax:
Practice Address - Street 1:5600 W MAPLE RD
Practice Address - Street 2:SUITE C-304
Practice Address - City:W BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3704
Practice Address - Country:US
Practice Address - Phone:248-855-5540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010430212084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2606308890OtherBLUE CROSS BLUE SHIELD
MIB43149Medicare UPIN
MI0M31590Medicare ID - Type Unspecified