Healthcare Provider Details

I. General information

NPI: 1548877947
Provider Name (Legal Business Name): MOUNT VERNON MEDICAL ENTERPRISES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2020
Last Update Date: 09/29/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4230 LINCOLNSHIRE DR STE G
MOUNT VERNON IL
62864-2189
US

IV. Provider business mailing address

4230 LINCOLNSHIRE DR STE G
MOUNT VERNON IL
62864-2189
US

V. Phone/Fax

Practice location:
  • Phone: 618-244-6770
  • Fax: 618-244-6772
Mailing address:
  • Phone: 618-244-6770
  • Fax: 618-244-6772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SUZANNE ALT
Title or Position: PRESIDENT
Credential: DO
Phone: 660-341-3877