Provider Demographics
NPI:1194827857
Name:LONGE, SUSAN H (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:H
Last Name:LONGE
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 1:435 N LEROY
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430
Mailing Address - Country:US
Mailing Address - Phone:810-629-3552
Mailing Address - Fax:810-629-3571
Practice Address - Street 1:435 N LEROY ST
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-2731
Practice Address - Country:US
Practice Address - Phone:810-629-3552
Practice Address - Fax:810-629-3571
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301059373207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1194827857Medicaid
MIG52621Medicare UPIN
MI1194827857Medicaid