Provider Demographics
NPI:1801873237
Name:TAM, SUSAN BETH (DO)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:BETH
Last Name:TAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:BETH
Other - Last Name:GURALSKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:390 ENTERPRISE CT
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-0320
Mailing Address - Country:US
Mailing Address - Phone:248-336-4000
Mailing Address - Fax:248-336-9137
Practice Address - Street 1:911 E 9 MILE RD
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-1934
Practice Address - Country:US
Practice Address - Phone:248-336-4000
Practice Address - Fax:248-336-9137
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5010013747207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4645569Medicaid
MI4645569Medicaid
MIM32970005Medicare PIN
OM32970Medicare ID - Type Unspecified