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Individual provider Active NPI

Susan Therese Fedewa, DO

  • Emergency Medicine Physician
  • Jackson, MI
National Provider Identifier
1750336004
Registry record updated Nov 23, 2007
On this page

Key facts

NPPES NPI Registry
Primary specialty
Emergency Medicine PhysicianTaxonomy code 207P00000X
License
5101010021 Issued in MI
Practice address
205 N East Ave
Jackson, MI 49201-1753
Phone
(517) 788-4800
Fax
(517) 796-6410
NPI assigned
May 24, 2006
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Nov 23, 2007

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Emergency Medicine Physician 207P00000X 5101010021 MI Primary

Addresses

Primary practice location

205 N East Ave
Jackson, MI 49201-1753

Mailing address

Department 272801
PO Box 67000
Detroit, MI 48267-2728
Phone (517) 841-6913

Other identifiers 2

IdentifierTypeStateIssuer
114873751MedicaidMI
P00312682OtherMIRR MEDICARE

Other names 1

  • Susan Therese Tartalone Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20040811001267 MI Practitioner - Emergency Medicine 7810896214 Reassigns benefits to 4 organizations

Care Compare profile

Medicare Care Compare
Specialty
Emergency Medicine
Education
Other, 1987
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Legacy Physician Group PCGroup PAC ID 0648277830, 11 clinicians

Practice addresses (Care Compare)

1540 Lake Lansing Rd
Suite 203
Lansing, MI 48912-3757
Phone (517) 913-6711

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Osteopathy

Practice roles

OrganizationSpecialtyStatusNew patients
Hillsdale Emergency Physicians, P.C. Emergency Medicine CurrentSince Jun 17, 2020 Accepting new patients
Emergency Professionals of Michigan, P.C. Emergency Medicine CurrentSince Aug 1, 2002 Accepting new patients
Legacy Physician Group, P.C. CurrentSince Nov 1, 2006 Accepting new patients
Ecs Central Michigan PC Emergency Medicine CurrentSince May 1, 2018 Accepting new patients
Emergency Department Physicians, P.C. Emergency Medicine Past Accepting new patients
Independent Emergency Physicians, P.C. PastSince Oct 12, 2025 Accepting new patients
Michigan Em-I Medical Services, P.C. Past Accepting new patients
Depot Emergency Physicians Emergency Medicine Past Accepting new patients

Locations

7300 N Canton Center Rd
Canton, MI 48187
Phone (734) 454-8001

18101 Oakwood Blvd
Ste 103G
Dearborn, MI 48124

168 S Howell St
Hillsdale, MI 49242
Phone (517) 437-4451

1540 Lake Lansing Rd
Ste 203
Lansing, MI 48912
Phone (517) 913-3855

826 W King St
Owosso, MI 48867
Phone (989) 720-2273

Organizations & group practices 8

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 4

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1148428800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1195776000000",
    "number": "1750336004",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "DEPARTMENT 272801",
            "address_2": "PO BOX 67000",
            "city": "DETROIT",
            "state": "MI",
            "postal_code": "482672728",
            "telephone_number": "517-841-6913",
            "fax_number": "517-841-6917"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "205 N EAST AVE",
            "city": "JACKSON",
            "state": "MI",
            "postal_code": "492011753",
            "telephone_number": "517-788-4800",
            "fax_number": "517-796-6410"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FEDEWA",
        "first_name": "SUSAN",
        "middle_name": "THERESE",
        "credential": "DO",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-05-24",
        "last_updated": "2007-11-23",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207P00000X",
            "taxonomy_group": "",
            "desc": "Emergency Medicine",
            "state": "MI",
            "license": "5101010021",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "114873751",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RR MEDICARE",
            "identifier": "P00312682",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "SUSAN",
            "last_name": "TARTALONE",
            "middle_name": "THERESE",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Jackson, MI

Sources for this page

Verify at the official NPI Registry.