Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RG0300X | Geriatric Medicine | 4301065763 | MI |
NPI | 1134198203 |
---|---|
Provider Name | Susan Allen |
First Address | Troy, MI 48084-1744 |
Second Address | Berkley, MI 48072-1868 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/03/2006 |
Last Update Date | 07/04/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0F349850 | BCBSM (01) | MI |
4266950 | (05) | MI |
H30116 | (02) | MI |