Provider Demographics
NPI:1720290943
Name:KATHRYN H. SUSSMAN, M.D. P.C.
Entity Type:Organization
Organization Name:KATHRYN H. SUSSMAN, M.D. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:H
Authorized Official - Last Name:SUSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-573-4980
Mailing Address - Street 1:28800 RYAN RD
Mailing Address - Street 2:SUITE 320
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-4272
Mailing Address - Country:US
Mailing Address - Phone:586-573-4980
Mailing Address - Fax:586-573-0640
Practice Address - Street 1:28800 RYAN RD
Practice Address - Street 2:SUITE 320
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-4272
Practice Address - Country:US
Practice Address - Phone:586-573-4980
Practice Address - Fax:586-573-0640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIKS050808OtherBLUECROSSBLUESHIELD
MI0705037252OtherBLUECROSSBLUE SHIELD
MI0E06271OtherBLUE CARE NETWORK
MI0M27850Medicare PIN