Healthcare Provider Details

I. General information

NPI: 1679856421
Provider Name (Legal Business Name): SUSAN MARIE ROSE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2011
Last Update Date: 09/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2345 S HURON PKWY
ANN ARBOR MI
48104-5124
US

IV. Provider business mailing address

525 VICTORIA SQ
BRIGHTON MI
48116-1107
US

V. Phone/Fax

Practice location:
  • Phone: 810-588-6911
  • Fax: 734-973-0518
Mailing address:
  • Phone: 810-217-3861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number5101007652
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: