Basic Information
| Provider Information | |||||||||
| NPI: | 1528144151 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DATTA | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751649 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437891620 | ||||||||
| FaxNumber: | 8437242440 | ||||||||
| Practice Location | |||||||||
| Address1: | 180 WINGO WAY | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | MT PLEASANT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294641810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438841777 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 11/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | LL27018 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 27018 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00924682 | 01 | SC | RAILROAD MEDICARE ID-RSFPN | OTHER | 270183 | 05 | SC | MEDICAID |