Provider Demographics
NPI:1578534889
Name:GOULD, SUSAN H (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:H
Last Name:GOULD
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 1:3611 HARBOR DR
Mailing Address - Street 2:
Mailing Address - City:ROCK FALLS
Mailing Address - State:IL
Mailing Address - Zip Code:61071-2227
Mailing Address - Country:US
Mailing Address - Phone:815-973-8410
Mailing Address - Fax:815-285-5865
Practice Address - Street 1:3611 HARBOR DR
Practice Address - Street 2:
Practice Address - City:ROCK FALLS
Practice Address - State:IL
Practice Address - Zip Code:61071-2227
Practice Address - Country:US
Practice Address - Phone:815-973-8410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067012207P00000X
MO2014012871207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036067012Medicaid
ILL81760Medicare PIN
ILL53040Medicare PIN
C42680Medicare UPIN