Provider Demographics
NPI:1952515603
Name:SHELLEY, SUSAN CATHERINE (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:CATHERINE
Last Name:SHELLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:
Practice Address - Street 1:318 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-1521
Practice Address - Country:US
Practice Address - Phone:864-879-3883
Practice Address - Fax:864-848-3492
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29403208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC294032Medicaid
SCAA39793640Medicare PIN
SC294032Medicaid