Provider Demographics
NPI:1780663815
Name:STUBER, SUSAN M (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:STUBER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:S
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 3099
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29578-3099
Mailing Address - Country:US
Mailing Address - Phone:843-716-7000
Mailing Address - Fax:843-716-7272
Practice Address - Street 1:3655 MITCHELL ST
Practice Address - Street 2:DEPARTMENT OF PATHOLOGY
Practice Address - City:LORIS
Practice Address - State:SC
Practice Address - Zip Code:29569-2827
Practice Address - Country:US
Practice Address - Phone:843-716-7000
Practice Address - Fax:843-716-7272
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15561207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC690566WMedicaid
SC155619Medicaid
SCF878986112Medicare PIN
220025066Medicare PIN
SC155619Medicaid