1316950330 NPI number — SUSAN S DANIEL LD

Table of content: SUSAN S DANIEL LD (NPI 1316950330)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316950330 NPI number — SUSAN S DANIEL LD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DANIEL
Provider First Name:
SUSAN
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STEWART
Provider Other First Name:
SUSAN
Provider Other Middle Name:
S
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1316950330
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1235 E CHEROKEE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65804-2203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-820-2000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1235 E CHEROKEE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65804-2203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-820-2000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/14/2006

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: 133V00000X , with the licence number:  2001001451 , 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: 357494103 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".