Healthcare Provider Details

I. General information

NPI: 1578534889
Provider Name (Legal Business Name): SUSAN H GOULD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 04/22/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3611 HARBOR DR
ROCK FALLS IL
61071-2227
US

IV. Provider business mailing address

3611 HARBOR DR
ROCK FALLS IL
61071-2227
US

V. Phone/Fax

Practice location:
  • Phone: 815-973-8410
  • Fax:
Mailing address:
  • Phone: 815-973-8410
  • Fax: 815-285-5865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036067012
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2014012871
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: