Healthcare Provider Details

I. General information

NPI: 1023073145
Provider Name (Legal Business Name): SUSAN STACKELHOUSE VOSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN STACKELHOUSE

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 02/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 MADISON ST
JEFFERSON CITY MO
65101-5227
US

IV. Provider business mailing address

1125 MADISON ST
JEFFERSON CITY MO
65101-5227
US

V. Phone/Fax

Practice location:
  • Phone: 573-632-5525
  • Fax: 573-632-5811
Mailing address:
  • Phone: 573-632-5525
  • Fax: 573-632-5811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number113335
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier440546366
Identifier TypeOTHER
Identifier State
Identifier IssuerUNITED HEALTH CARE
# 2
IdentifierH16641
Identifier TypeOTHER
Identifier State
Identifier IssuerMERCY
# 3
Identifier1834230
Identifier TypeOTHER
Identifier State
Identifier IssuerFIRST HEALTH
# 4
Identifier204990105
Identifier TypeOTHER
Identifier StateMO
Identifier IssuerMEDICAID
# 5
Identifier207515500
Identifier TypeOTHER
Identifier StateMO
Identifier IssuerMEDICAID
# 6
Identifier11071
Identifier TypeOTHER
Identifier State
Identifier IssuerCIGNA
# 7
Identifier204990105
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer
# 8
Identifier129170
Identifier TypeOTHER
Identifier State
Identifier IssuerBLUE CROSS BLUE SHIELD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: