Provider Demographics
NPI:1053356899
Name:KNOLL-VLACHOS, SUSAN J (DO)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:KNOLL-VLACHOS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:J
Other - Last Name:KNOLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:28080 GRAND RIVER AVE STE 306
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-5966
Practice Address - Country:US
Practice Address - Phone:947-521-8314
Practice Address - Fax:248-478-8864
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009680207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC2556OtherMCARE
MI127336OtherCARE CHOICES
MI2869043Medicaid
MI4456347854OtherBLUE CROSS
MI4382684OtherAETNA
MI5634785OtherBLUE CROSS
MI127336OtherCARE CHOICES
F38758Medicare UPIN