Provider Demographics
NPI:1316222557
Name:SUSAN BURGE DO SC
Entity Type:Organization
Organization Name:SUSAN BURGE DO SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:BURGE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:217-323-9703
Mailing Address - Street 1:111 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:BEARDSTOWN
Mailing Address - State:IL
Mailing Address - Zip Code:62618-1217
Mailing Address - Country:US
Mailing Address - Phone:217-323-9703
Mailing Address - Fax:217-323-9706
Practice Address - Street 1:111 S STATE ST
Practice Address - Street 2:
Practice Address - City:BEARDSTOWN
Practice Address - State:IL
Practice Address - Zip Code:62618-1217
Practice Address - Country:US
Practice Address - Phone:217-323-9703
Practice Address - Fax:217-323-9706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036119873207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty