Provider Demographics
NPI:1194787424
Name:HARRIS, SUSAN LOUISE (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:LOUISE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 BROWN ST
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-3203
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:911 BROWN ST
Practice Address - Street 2:700 KMS PLACE
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-3203
Practice Address - Country:US
Practice Address - Phone:734-936-2047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080319208000000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101377820Medicaid
MIF06422Medicare ID - Type Unspecified
MI101377820Medicaid