Provider Demographics
NPI:1548299191
Name:LUBEROFF, SUSAN B (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:B
Last Name:LUBEROFF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:RYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:3710 LANDMARK DRIVE
Practice Address - Street 2:SUITE 300
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-4034
Practice Address - Country:US
Practice Address - Phone:803-898-1470
Practice Address - Fax:803-898-1471
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12414208000000X, 2080C0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080C0008XAllopathic & Osteopathic PhysiciansPediatricsChild Abuse Pediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC124145Medicaid
SC124145Medicaid
SCAA69332389Medicare PIN
SCB917182389Medicare PIN