Healthcare Provider Details

I. General information

NPI: 1750332680
Provider Name (Legal Business Name): SUSY ALIAS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: SUSY ALIAS MD

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JEFFERSON BARRACKS DR JEFFERSON BARRACKS, VA
SAINT LOUIS MO
63125-4181
US

IV. Provider business mailing address

1 JB DRIVE JEFFERSON BARRACKS
ST, LOUIS MO
63125
US

V. Phone/Fax

Practice location:
  • Phone: 314-894-6629
  • Fax: 314-845-5077
Mailing address:
  • Phone: 314-894-6629
  • Fax: 314-845-5077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberR9895
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberR9895
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: