Provider Demographics
NPI:1528288560
Name:SUSAC-PAVIC, STELA (MD)
Entity type:Individual
Prefix:
First Name:STELA
Middle Name:
Last Name:SUSAC-PAVIC
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:PO BOX 41189
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29423-1189
Mailing Address - Country:US
Mailing Address - Phone:843-501-2031
Mailing Address - Fax:843-884-6146
Practice Address - Street 1:1305 HORSESHOE BND
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-7406
Practice Address - Country:US
Practice Address - Phone:843-501-2031
Practice Address - Fax:843-884-6146
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC01577207Q00000X
SC35609207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC01577OtherMEDICAL LICENSE
SC356091Medicaid
SC35609OtherSOUTH CAROLINA MEDICAL LICENCE