Healthcare Provider Details

I. General information

NPI: 1598987836
Provider Name (Legal Business Name): SUSAN L JOURNAGAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 11/07/2024
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 OFFICE COURT
FAIRVIEW HEIGHTS IL
62208
US

IV. Provider business mailing address

390 OFFICE COURT
FAIRVIEW HEIGHTS IL
62208
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-7666
  • Fax: 618-233-7461
Mailing address:
  • Phone: 618-233-7666
  • Fax: 618-233-7461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036117994
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: