Basic Information
| Provider Information | |||||||||
| NPI: | 1922087790 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILJKOVIC-GOODRICH | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 970 E WASHINGTON ST | ||||||||
| Address2: | SUITE 6-C | ||||||||
| City: | MEDINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442563332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307223083 | ||||||||
| FaxNumber: | 3307255043 | ||||||||
| Practice Location | |||||||||
| Address1: | 970 E WASHINGTON ST | ||||||||
| Address2: | SUITE 6-C | ||||||||
| City: | MEDINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442563332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307223083 | ||||||||
| FaxNumber: | 3307255043 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 246ZS0410X | 35-082575M | OH | Y |
ID Information
| ID | Type | State | Issuer | Description | 2500163 | 05 | OH | MEDICAID |