1447257571 NPI number — SUSAN MARY BURKHART M.D.

Table of content: SUSAN MARY BURKHART M.D. (NPI 1447257571)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447257571 NPI number — SUSAN MARY BURKHART M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURKHART
Provider First Name:
SUSAN
Provider Middle Name:
MARY
Provider Name Prefix Text:
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:
1447257571
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 1027
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JEFFERSON CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65102-1027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-761-7246
Provider Business Mailing Address Fax Number:
573-761-6947

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 KIDWELL DRIVE
Provider Second Line Business Practice Location Address:
ST MARY'S CLINIC
Provider Business Practice Location Address City Name:
VERSAILLES
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65084
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-378-5454
Provider Business Practice Location Address Fax Number:
573-378-5055
Provider Enumeration Date:
07/05/2005

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: 208D00000X , with the licence number:  104938 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 104938 , 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: 33968017 . This is a "BCBS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 207903022 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2007903022 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 853019 . This is a "FRIST HEALTH" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 32329 . This is a "FAMILY HEALTH PARTNERS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 5487 . This is a "HEALTH CARE USA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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