Healthcare Provider Details

I. General information

NPI: 1447257571
Provider Name (Legal Business Name): SUSAN MARY BURKHART M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 09/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 KIDWELL DRIVE ST MARY'S CLINIC
VERSAILLES MO
65084
US

IV. Provider business mailing address

P.O. BOX 1027
JEFFERSON CITY MO
65102-1027
US

V. Phone/Fax

Practice location:
  • Phone: 573-378-5454
  • Fax: 573-378-5055
Mailing address:
  • Phone: 573-761-7246
  • Fax: 573-761-6947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number104938
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number104938
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: