Provider Demographics
NPI:1205996303
Name:OLSON, SUSAN JAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:JAYNE
Last Name:OLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:333 WELCOME DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-5374
Mailing Address - Country:US
Mailing Address - Phone:843-712-1854
Mailing Address - Fax:843-213-1681
Practice Address - Street 1:1297 PROFESSIONAL DR
Practice Address - Street 2:STE 104
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5713
Practice Address - Country:US
Practice Address - Phone:843-712-1854
Practice Address - Fax:843-213-1681
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI260142084A0401X
SC297522084A0401X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30823300Medicaid
E97214Medicare UPIN
WI30823300Medicaid