Healthcare Provider Details

I. General information

NPI: 1598767394
Provider Name (Legal Business Name): SUSAN J VANDELLEN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 12/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 RIVER CENTRE DR
PORT HURON MI
48060-4463
US

IV. Provider business mailing address

940 RIVER CENTRE DR
PORT HURON MI
48060-4463
US

V. Phone/Fax

Practice location:
  • Phone: 810-985-4900
  • Fax: 810-985-3634
Mailing address:
  • Phone: 810-985-4900
  • Fax: 810-985-3634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number5101009277
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: