Provider Demographics
NPI:1760062814
Name:RUSZALA, MADELINE
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:RUSZALA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MADELINE
Other - Middle Name:
Other - Last Name:CONLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3031 W GRAND BLVD STE 600
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22500 METRO PKWY STE 201
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48035-1943
Practice Address - Country:US
Practice Address - Phone:586-493-3732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-13
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101028033208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics