Healthcare Provider Details

I. General information

NPI: 1811995566
Provider Name (Legal Business Name): SUZANNE E ALT DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUZANNE ALT JARBOE D.O

II. Dates (important events)

Enumeration Date: 07/07/2005
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

1715 W WORLEY ST STE B
COLUMBIA MO
65203-1015
US

V. Phone/Fax

Practice location:
  • Phone: 618-244-6770
  • Fax: 618-244-6772
Mailing address:
  • Phone: 660-341-3877
  • Fax: 573-875-4879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberR9G62
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR9G62
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: