Basic Information
Provider Information | |||||||||
NPI: | 1114155447 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MILLER | ||||||||
FirstName: | SUSAN | ||||||||
MiddleName: | NEY | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | NEY | ||||||||
OtherFirstName: | SUSAN | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 751069 | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282751069 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2100 STANTONSBURG RD | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 278342818 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2527444757 | ||||||||
FaxNumber: | 2527444125 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/25/2009 | ||||||||
LastUpdateDate: | 12/01/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/01/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 25MA08708600 | NJ | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | MT186185 | PA | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207PT0002X | MT186185 | PA | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine | Medical Toxicology | 207PT0002X | 2011-01495 | NC | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine | Medical Toxicology | 207P00000X | 2011-01495 | NC | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | MA08708600 | 01 | NJ | STATE LICENSE | OTHER | 165GX | 01 | NC | BCBSNC | OTHER | 5918877 | 05 | NC |   | MEDICAID |