Healthcare Provider Details

I. General information

NPI: 1497841589
Provider Name (Legal Business Name): SUSAN M BUBLICK P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 08/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

870 COLFAX AVE
BENTON HARBOR MI
49022-7409
US

IV. Provider business mailing address

50 INDUSTRIAL PARK RD
BANGOR MI
49013-1246
US

V. Phone/Fax

Practice location:
  • Phone: 269-927-5400
  • Fax: 269-927-5493
Mailing address:
  • Phone: 269-427-7937
  • Fax: 269-427-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10000822
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601002144
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: