Provider Demographics
NPI:1750324109
Name:CARLSON, SUSAN M (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:M
Last Name:CARLSON
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 1:601 JOHN ST
Mailing Address - Street 2:SUITE M170A
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-381-5060
Mailing Address - Fax:269-381-1655
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:SUITE M170A
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-381-5060
Practice Address - Fax:269-381-1655
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301075680207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
7375227OtherAETNA PIN
155415OtherGREAT LAKES HTLH PLN
MI4335118-10Medicaid
MI0390552OtherBCBS IND PIN
MI110C910470OtherBCBS GRP PIN
7375227OtherAETNA PIN
155415OtherGREAT LAKES HTLH PLN
H31082Medicare UPIN
MI0C97625078Medicare ID - Type Unspecified
383148262OtherEIN-HEALTHCARE MIDWEST