Healthcare Provider Details

I. General information

NPI: 1770544892
Provider Name (Legal Business Name): AARON MICHAEL SUESSEN M.S. ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

746 N PRAIRIE ST
BETHALTO IL
62010-1329
US

IV. Provider business mailing address

746 N PRAIRIE ST
BETHALTO IL
62010-1329
US

V. Phone/Fax

Practice location:
  • Phone: 618-377-6941
  • Fax:
Mailing address:
  • Phone: 618-377-6941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: