Provider Demographics
NPI:1376570895
Name:DEMERE, SUSAN D (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:D
Last Name:DEMERE
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:255 ENTERPRISE BLVD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-6300
Mailing Address - Country:US
Mailing Address - Phone:864-454-0888
Mailing Address - Fax:864-454-1130
Practice Address - Street 1:PIVITAL THERAPY
Practice Address - Street 2:1020 GROVE ROAD
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605
Practice Address - Country:US
Practice Address - Phone:864-455-2319
Practice Address - Fax:864-455-2340
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC4177225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC9799717OtherCIGNA INTERNAL GRP #
SC213663OtherMEDCOST
SCTH1665Medicaid
SCQ34004Medicare ID - Type UnspecifiedMEDICARE ID