Provider Demographics
NPI:1447908074
Name:SUPER, ROBERT SCOTT (DC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:SCOTT
Last Name:SUPER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX PO BOX 772813
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48277-0001
Mailing Address - Country:US
Mailing Address - Phone:877-401-1440
Mailing Address - Fax:727-821-8913
Practice Address - Street 1:16250 NORTHLAND DR # 223
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-5205
Practice Address - Country:US
Practice Address - Phone:877-401-1440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301011062111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2301011062OtherSTATE LICENSE