Provider Demographics
NPI:1073546610
Name:GARNER, SUSAN LEAH (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEAH
Last Name:GARNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 MEDICAL PARK DR STE 402
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9010
Mailing Address - Country:US
Mailing Address - Phone:304-842-1034
Mailing Address - Fax:304-842-1037
Practice Address - Street 1:916 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1651
Practice Address - Country:US
Practice Address - Phone:304-842-1034
Practice Address - Fax:304-842-1037
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20198207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810005391Medicaid
WVWV3793AOtherMEDICARE PTAN
WV3810005391Medicaid
4097661Medicare PIN
H75457Medicare UPIN