Provider Demographics
NPI:1770692873
Name:NOBLE, SUSAN C (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:NOBLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:550 MUNSON AVENUE, SUITE 200
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686
Mailing Address - Country:US
Mailing Address - Phone:231-935-8717
Mailing Address - Fax:231-935-9230
Practice Address - Street 1:550 MUNSON AVENUE, SUITE 200
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686
Practice Address - Country:US
Practice Address - Phone:231-935-8717
Practice Address - Fax:231-935-9230
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301406284207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0702821712OtherBLUE CROSS BLUE SHIELD
MI1997138Medicaid
MIM008816OtherTRICARE
MI38-2170687OtherPRIORITY HEALTH
MI070002527OtherRAILROAD MEDICARE
E50129Medicare UPIN
MI1997138Medicaid