Provider Demographics
NPI:1891875340
Name:ANDERSEN, SUSAN H (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:H
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:H
Other - Last Name:ANDERSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1702 MEDICAL PARK DR W
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-2705
Mailing Address - Country:US
Mailing Address - Phone:252-243-7944
Mailing Address - Fax:252-243-6097
Practice Address - Street 1:1702 MEDICAL PARK DR W
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-2705
Practice Address - Country:US
Practice Address - Phone:252-243-7944
Practice Address - Fax:252-243-6097
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32333208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8911095Medicaid
NCC82597Medicare UPIN