Provider Demographics
NPI:1174631337
Name:HOLTHAUS, SUZANNE E (MD)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:E
Last Name:HOLTHAUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520-2608
Mailing Address - Country:US
Mailing Address - Phone:309-647-0201
Mailing Address - Fax:309-649-5101
Practice Address - Street 1:180 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-2608
Practice Address - Country:US
Practice Address - Phone:309-647-0201
Practice Address - Fax:309-649-6880
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036100703207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL0132OtherJOHN DEERE
IL080160949OtherRR MEDICARE PIN
ILCG5172OtherRR MEDICARE GROUP#
IL0062839OtherUMWA
IL02922981OtherBCBS
IL445841OtherHEALTH LINK
IL200397OtherBLACK LUNG
IL062751OtherHEALTH ALLIANCE
IL100703OtherOSF HEALTHPLANS
IL036100703Medicaid
ILCG5172OtherRR MEDICARE GROUP#
IL100703OtherOSF HEALTHPLANS
IL036100703Medicaid