Basic Information
| Provider Information | |||||||||
| NPI: | 1326026501 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STRICH | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | HERDERICH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HEPKER | ||||||||
| OtherFirstName: | SUSAN | ||||||||
| OtherMiddleName: | HERDERICH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1140 NORTH STATE STREET | ||||||||
| Address2: | |||||||||
| City: | SAINT IGNACE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49781 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9066438585 | ||||||||
| FaxNumber: | 9066439036 | ||||||||
| Practice Location | |||||||||
| Address1: | 1140 NORTH STATE STREET | ||||||||
| Address2: | |||||||||
| City: | SAINT IGNACE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49781 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9066438585 | ||||||||
| FaxNumber: | 9066439036 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2006 | ||||||||
| LastUpdateDate: | 12/20/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301057631 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 057631 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0G71004 | 01 | MI | RHC BLUE CROSS | OTHER | 103240440 | 05 | MI | MEDICAID | 3240440 | 05 | MI | MEDICAID |