Provider Demographics
NPI:1497841589
Name:BUBLICK, SUSAN M (PA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:BUBLICK
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:50 INDUSTRIAL PARK RD
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:MI
Mailing Address - Zip Code:49013-1246
Mailing Address - Country:US
Mailing Address - Phone:269-427-7937
Mailing Address - Fax:269-427-5180
Practice Address - Street 1:870 COLFAX AVE
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-7409
Practice Address - Country:US
Practice Address - Phone:269-927-5400
Practice Address - Fax:269-927-5493
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2012-08-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN10000822363A00000X
MI5601002144363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN219950C2Medicare PIN