Provider Demographics
NPI:1497858609
Name:CHRISCO-WILCOX, SUZANNE RINEHART (CNM)
Entity type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:RINEHART
Last Name:CHRISCO-WILCOX
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-4409
Mailing Address - Country:US
Mailing Address - Phone:269-985-9855
Mailing Address - Fax:
Practice Address - Street 1:800 M-139
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-4843
Practice Address - Country:US
Practice Address - Phone:269-927-5400
Practice Address - Fax:269-927-5493
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704215737367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4790588Medicaid
MIOA1474200Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER