Provider Demographics
NPI:1487853750
Name:SUSAN E. PEARSON, LLC
Entity Type:Organization
Organization Name:SUSAN E. PEARSON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:PEARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:636-244-4500
Mailing Address - Street 1:6209 MIDRIVERS MALL DR
Mailing Address - Street 2:#317
Mailing Address - City:ST CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63304-1102
Mailing Address - Country:US
Mailing Address - Phone:636-244-4500
Mailing Address - Fax:636-244-4505
Practice Address - Street 1:6209 MIDRIVERS MALL DR
Practice Address - Street 2:#317
Practice Address - City:ST CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63304-1102
Practice Address - Country:US
Practice Address - Phone:636-244-4500
Practice Address - Fax:636-244-4505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODO101125207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOG19945Medicare UPIN