Provider Demographics
NPI:1770118523
Name:SUSMILCH, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:SUSMILCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13525
Mailing Address - Street 2:
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113-0525
Mailing Address - Country:US
Mailing Address - Phone:901-833-4404
Mailing Address - Fax:866-251-1267
Practice Address - Street 1:2528 W 16TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-4955
Practice Address - Country:US
Practice Address - Phone:970-356-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-11
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant