Healthcare Provider Details

I. General information

NPI: 1992781397
Provider Name (Legal Business Name): SUSAN B CHAMBERLAIN MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2363 W JEFFERSON AVE
TRENTON MI
48183-2705
US

IV. Provider business mailing address

2363 W JEFFERSON AVE
TRENTON MI
48183-2705
US

V. Phone/Fax

Practice location:
  • Phone: 734-676-2800
  • Fax: 734-676-4418
Mailing address:
  • Phone: 734-676-2800
  • Fax: 734-676-4418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberHC078265
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberSC407053
License Number StateMI

VIII. Authorized Official

Name: SUSAN B CHAMBERLAIN
Title or Position: OWNER
Credential: MD
Phone: 734-676-2800