Basic Information
| Provider Information | |||||||||
| NPI: | 1164488870 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BARNES | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5701 BOW POINTE DR STE 315 | ||||||||
| Address2: | |||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483465402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486254000 | ||||||||
| FaxNumber: | 2486252622 | ||||||||
| Practice Location | |||||||||
| Address1: | 6815 DIXIE HWY STE 1 | ||||||||
| Address2: | |||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483462092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483848360 | ||||||||
| FaxNumber: | 2483848360 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2006 | ||||||||
| LastUpdateDate: | 11/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 5101011977 | MI | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 4510933 | 05 | MI | MEDICAID |