1528288560 NPI number — STELA SUSAC-PAVIC M.D.

Table of content: STELA SUSAC-PAVIC M.D. (NPI 1528288560)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528288560 NPI number — STELA SUSAC-PAVIC M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUSAC-PAVIC
Provider First Name:
STELA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1528288560
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 41189
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH CHARLESTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29423-1189
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-501-2031
Provider Business Mailing Address Fax Number:
843-884-6146

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1305 HORSESHOE BND
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MT PLEASANT
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29464-7406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-501-2031
Provider Business Practice Location Address Fax Number:
843-884-6146
Provider Enumeration Date:
05/01/2007

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: 207Q00000X , with the licence number:  01577 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QA0505X , with the licence number: 35609 , 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: 01577 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 356091 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 35609 . This is a "SOUTH CAROLINA MEDICAL LICENCE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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