Provider Demographics
NPI:1376504365
Name:STRAYER, SUE A (MD)
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:A
Last Name:STRAYER
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:PO BOX 790129
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63179-0129
Mailing Address - Country:US
Mailing Address - Phone:217-964-2966
Mailing Address - Fax:217-464-3193
Practice Address - Street 1:1800 E LAKE SHORE DRIVE
Practice Address - Street 2:ST MARYS-DECATUR
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3883
Practice Address - Country:US
Practice Address - Phone:217-464-2966
Practice Address - Fax:217-464-3193
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360800151Medicaid
IL986060Medicare ID - Type Unspecified
ILL21986Medicare ID - Type Unspecified
IL416390Medicare ID - Type Unspecified
E49819Medicare UPIN
IL0360800151Medicaid