Healthcare Provider Details

I. General information

NPI: 1003819137
Provider Name (Legal Business Name): SUSAN MARIE MOU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 08/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 CHARLOTTE ST
KANSAS CITY MO
64108-2727
US

IV. Provider business mailing address

2310 HOLMES ST STE 800
KANSAS CITY MO
64108-2602
US

V. Phone/Fax

Practice location:
  • Phone: 816-404-7820
  • Fax: 816-404-8159
Mailing address:
  • Phone: 816-218-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberR8D92
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: