Healthcare Provider Details

I. General information

NPI: 1700136520
Provider Name (Legal Business Name): INDEPENDENT EMERGENCY PHYSICIANS P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 09/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 NORTH EAST AVENUE EMERGENCY DEPARTMENT
JACKSON MI
49201
US

IV. Provider business mailing address

PO BOX 100
ROYAL OAK MI
48068-0100
US

V. Phone/Fax

Practice location:
  • Phone: 517-788-4800
  • Fax:
Mailing address:
  • Phone: 248-849-3137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1784233
License Number StateMI

VIII. Authorized Official

Name: JULIE SUSIN
Title or Position: BUSINESS MANAGER
Credential: MBA
Phone: 248-892-0715