1174529275 NPI number — DR. SUSAN SCHUCK JOHNSON M.D.

Table of content: ASHLY PATTERSON M.A. (NPI 1740980119)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174529275 NPI number — DR. SUSAN SCHUCK JOHNSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
SUSAN
Provider Middle Name:
SCHUCK
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174529275
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
670 MASON RIDGE CENTER DR
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63141-8573
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-499-9009
Provider Business Mailing Address Fax Number:
573-499-4400

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 W NIFONG STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-499-9009
Provider Business Practice Location Address Fax Number:
573-499-4400
Provider Enumeration Date:
06/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  36736 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 127771 . This is a "GROUP HEALTH PLANS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: A002 . This is a "TRICARE IND" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: AI3068 . This is a "MERCY" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 669715 . This is a "FIRST HEALTH" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: P00187205 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 0404040 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 102600 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 5422 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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