Provider Demographics
NPI:1093709701
Name:CHURCH, SUSAN L (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:CHURCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 NASH MEDICAL ARTS MALL
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-1400
Mailing Address - Country:US
Mailing Address - Phone:252-451-3100
Mailing Address - Fax:252-451-3141
Practice Address - Street 1:100 NASH MEDICAL ARTS MALL
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-1400
Practice Address - Country:US
Practice Address - Phone:252-451-3100
Practice Address - Fax:252-451-3141
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28956208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC22480OtherBCBSNC
NC7922480Medicaid
NC1521919OtherCIGNA HEALTHCARE
NC69963OtherMEDCOST
NC22480OtherBCBSNC
NCF87948Medicare UPIN