Provider Demographics
NPI:1174531040
Name:RADTKE, SUSAN A (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:RADTKE
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 1:21321 HARPER
Mailing Address - Street 2:SUITE A
Mailing Address - City:ST. CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080
Mailing Address - Country:US
Mailing Address - Phone:586-776-0797
Mailing Address - Fax:586-776-4910
Practice Address - Street 1:21321 HARPER
Practice Address - Street 2:SUITE A
Practice Address - City:ST. CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080
Practice Address - Country:US
Practice Address - Phone:586-776-0797
Practice Address - Fax:586-776-4910
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI038554207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2912609Medicaid
08277832161Medicare ID - Type Unspecified
A76146Medicare UPIN