Healthcare Provider Details

I. General information

NPI: 1558484345
Provider Name (Legal Business Name): JOEL P. SUSSMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 BUSINESS PARK BOULEVARD
COLUMBIA SC
29203
US

IV. Provider business mailing address

2 TIFTGREEN CIRCLE
COLUMBIA SC
29223
US

V. Phone/Fax

Practice location:
  • Phone: 803-462-1234
  • Fax: 803-462-2007
Mailing address:
  • Phone: 803-788-2409
  • Fax: 803-736-7882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number07628
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: