Provider Demographics
NPI:1881074524
Name:MBU, SUSAN (DO)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MBU
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-695-6294
Mailing Address - Fax:803-774-2759
Practice Address - Street 1:22725 HIGHWAY 76 E
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:SC
Practice Address - Zip Code:29325-7527
Practice Address - Country:US
Practice Address - Phone:864-833-9100
Practice Address - Fax:864-833-9458
Is Sole Proprietor?:No
Enumeration Date:2015-06-08
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2022-02917207R00000X, 208M00000X
SC83012208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXUNSUREMedicaid