Healthcare Provider Details

I. General information

NPI: 1275816175
Provider Name (Legal Business Name): SUSAN E EADELMAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

1091 S BEACON BLVD
GRAND HAVEN MI
49417-2607
US

IV. Provider business mailing address

1091 S BEACON BLVD
GRAND HAVEN MI
49417-2607
US

V. Phone/Fax

Practice location:
  • Phone: 616-604-0096
  • Fax: 616-604-0095
Mailing address:
  • Phone: 616-604-0096
  • Fax: 616-604-0095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704214274
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: