MEDICARE: MRS. SUZANNE S. GOLDEN LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	2001015381	MO

General Provider Information

NPI Number	:	1093886574
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUZANNE S. GOLDEN LMT

Provider Business Mailing Address
First Line	:	549 PROSPECTOR RIDGE DR
Second Line	:
City	:	WILDWOOD
State	:	MO
Zip	:	63011-4806
Country	:	US
Telephone Number	:	636-458-8777
Fax Number	:	636-273-1244

Provider Business Practice Location Address
First Line	:	549 PROSPECTOR RIDGE DR
Second Line	:
City	:	WILDWOOD
State	:	MO
Zip	:	63011-4806
Country	:	US
Telephone Number	:	636-458-8777
Fax Number	:	636-273-1244

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/13/2006
Last Update Date	:	07/08/2007

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