Provider Demographics
NPI:1417048513
Name:CAMPBELL, SUSAN LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:LEE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:CAMPBELL
Other - Last Name:DUNCAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:124 MALLARD ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-4046
Mailing Address - Country:US
Mailing Address - Phone:864-241-1040
Mailing Address - Fax:864-241-1049
Practice Address - Street 1:124 MALLARD ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-4046
Practice Address - Country:US
Practice Address - Phone:864-241-1040
Practice Address - Fax:864-241-1049
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC134492084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC301100Medicaid
SC301100Medicaid
E33518Medicare UPIN