Basic Information
| Provider Information | |||||||||
| NPI: | 1497731400 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DORENBUSCH | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 775383 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606775383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123753000 | ||||||||
| FaxNumber: | 8123753477 | ||||||||
| Practice Location | |||||||||
| Address1: | 3183 N NATIONAL RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472013164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123721581 | ||||||||
| FaxNumber: | 8123764028 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2005 | ||||||||
| LastUpdateDate: | 07/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 01039024 | IN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 000000984533 | 01 | IN | ANTHEM PIN | OTHER | 100384130A | 05 | IN | MEDICAID | 000000511861 | 01 | IN | ANTHEM | OTHER |