Individual
SUSAN GAIL STAVISS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
3939 ROSWELL RD, SUITE 300, MARIETTA, GA 30062-6251
(770) 578-2868
(770) 971-8499
Mailing address
3939 ROSWELL RD, SUITE 300, MARIETTA, GA 30062-6251
(770) 578-2868
(770) 971-8499
Taxonomy
Speciality
Code
Description
License number
State
2080A0000X
Pediatric Adolescent Medicine Physician
Primary
038652
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000607703D
—
GA
01
—
241020
PRIVATE HEALTHCARE SYSTEM
GA
01
—
3308662027
CIGNA
GA
01
—
4508167
AETNA USHEALTHCARE
GA
Enumeration date
08/11/2005
Last updated
10/02/2019
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