Provider Demographics
NPI:1528308319
Name:SEMMES, SUSAN GROGAN (CPO/LPO)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:GROGAN
Last Name:SEMMES
Suffix:
Gender:F
Credentials:CPO/LPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 NORTHSIDE DR
Mailing Address - Street 2:STE D
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1866
Mailing Address - Country:US
Mailing Address - Phone:229-245-8009
Mailing Address - Fax:229-247-2090
Practice Address - Street 1:404 NORTHSIDE DR
Practice Address - Street 2:STE D
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1866
Practice Address - Country:US
Practice Address - Phone:229-245-8009
Practice Address - Fax:229-247-2090
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-15
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA 000004222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000690852AMedicaid
GAC15505OtherBOC CPO
GALPO 000004OtherGEORGIA LICENSE
GACPO02244OtherABC CPO
GALPO 000004OtherGEORGIA LICENSE