1366433294 NPI number — SUSAN ELLEN MYERS WHNPC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366433294 NPI number — SUSAN ELLEN MYERS WHNPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MYERS
Provider First Name:
SUSAN
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
WHNPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366433294
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1453 DIAMOND BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MT PLEASANT
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29466-9464
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-849-8523
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 CHARLESTON CENTER DR
Provider Second Line Business Practice Location Address:
CHARLESTON COUNTY HEALTH CLINIC
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29401-1162
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-579-4606
Provider Business Practice Location Address Fax Number:
843-570-4621
Provider Enumeration Date:
10/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LW0102X , with the licence number:  APN 620 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 16 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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