Healthcare Provider Details

I. General information

NPI: 1447328299
Provider Name (Legal Business Name): SUSAN MARIE OTT D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 04/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 E WILLIAMS ST
OWOSSO MI
48867-2360
US

IV. Provider business mailing address

1575 RAMBLEWOOD DR
EAST LANSING MI
48823-6384
US

V. Phone/Fax

Practice location:
  • Phone: 989-725-6101
  • Fax: 989-723-3601
Mailing address:
  • Phone: 989-725-6528
  • Fax: 989-723-9446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number5101012156
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: