Provider Demographics
NPI:1497179295
Name:SUSAN S. CROCKER, M.D., LLC
Entity Type:Organization
Organization Name:SUSAN S. CROCKER, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:CROCKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:842-408-2945
Mailing Address - Street 1:709 OLD TROLLEY RD
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-5203
Mailing Address - Country:US
Mailing Address - Phone:843-821-2480
Mailing Address - Fax:843-875-3149
Practice Address - Street 1:709 OLD TROLLEY RD
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-5203
Practice Address - Country:US
Practice Address - Phone:843-821-2480
Practice Address - Fax:843-875-3149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-13
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD93082084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AA30060281Medicare UPIN