Healthcare Provider Details

I. General information

NPI: 1104819085
Provider Name (Legal Business Name): SUSHILA S RAO
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 LINDEN ST SUITE 4
BIG RAPIDS MI
49307-1879
US

IV. Provider business mailing address

650 LINDEN ST SUITE 4
BIG RAPIDS MI
49307-1879
US

V. Phone/Fax

Practice location:
  • Phone: 231-796-4470
  • Fax: 231-796-1605
Mailing address:
  • Phone: 231-796-4470
  • Fax: 231-796-1605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301060779
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: