Provider Demographics
NPI:1841294410
Name:PHILLIPS, SUSAN M (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:2249 WEALTHY ST SE
Mailing Address - Street 2:STE 110
Mailing Address - City:EAST GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-3052
Mailing Address - Country:US
Mailing Address - Phone:616-391-4600
Mailing Address - Fax:616-486-0133
Practice Address - Street 1:2249 WEALTHY ST SE
Practice Address - Street 2:STE 110
Practice Address - City:EAST GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-3052
Practice Address - Country:US
Practice Address - Phone:616-391-4600
Practice Address - Fax:616-486-0133
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2022-07-08
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Provider Licenses
StateLicense IDTaxonomies
MI4301052812207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5210673Medicaid
MI0D16321OtherMEDICARE GROUP NUMBER
MIF05000Medicare UPIN