Basic Information
| Provider Information | |||||||||
| NPI: | 1205889920 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOLTANSKI | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KINGERY | ||||||||
| OtherFirstName: | SUZANNE | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 29130 RIVERBANK ST | ||||||||
| Address2: | |||||||||
| City: | HARRISON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480451633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864637432 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13355 E 10 MILE RD | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480892048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867597510 | ||||||||
| FaxNumber: | 5867597791 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4301059819 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 4609286 | 05 | MI | MEDICAID |