Provider Demographics
NPI:1568431013
Name:SUZANNE E. ALT, D.O., LLC
Entity Type:Organization
Organization Name:SUZANNE E. ALT, D.O., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:E
Authorized Official - Last Name:ALT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:660-665-0817
Mailing Address - Street 1:PO BOX 1043
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-1043
Mailing Address - Country:US
Mailing Address - Phone:913-248-9693
Mailing Address - Fax:913-248-9383
Practice Address - Street 1:2605 N BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-5116
Practice Address - Country:US
Practice Address - Phone:660-665-0817
Practice Address - Fax:660-665-2398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-16
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO-R9G62207Q00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
38463011OtherBLUE SHIELD KC, MO
38463011OtherBLUE SHIELD KC, MO
KST390000AMedicare PIN