MEDICARE: DR. SUSAN DALE CHARLAMB MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	4301043021	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2606308890	OTHER	MI	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1396826418
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN DALE CHARLAMB MD

Provider Business Mailing Address
First Line	:	5600 W MAPLE RD
Second Line	:	SUITE C-304
City	:	W BLOOMFIELD
State	:	MI
Zip	:	48322-3704
Country	:	US
Telephone Number	:	248-855-5540
Fax Number	:

Provider Business Practice Location Address
First Line	:	5600 W MAPLE RD
Second Line	:	SUITE C-304
City	:	W BLOOMFIELD
State	:	MI
Zip	:	48322-3704
Country	:	US
Telephone Number	:	248-855-5540
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2006
Last Update Date	:	07/08/2007

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