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General NPI Number Information
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NPI Number | 1225565377
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Entity Type | Individual
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Provider Name | SUSAN J SAM
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Gender | Female
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Dates
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Enumeration Date | 05/20/2017
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Last Update Date | 01/06/2021
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Provider Practice Location Address
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Address Line | 468 CADIEUX RD
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City | GROSSE POINTE
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State | MI
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Zip | 48230-1507
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Country | US
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Telephone | 313-473-1605
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Fax |
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Provider Business Mailing Address
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Address Line | 7146 N CENTRAL PARK
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City | SHELBY TWP
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State | MI
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Zip | 48317-2388
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Country | US
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Telephone | 586-722-3339
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 4704257975
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 163WM0705X
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Taxonomy Name | Medical-Surgical Registered Nurse
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License Number | 4704257975
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License Number State | MI
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