Provider Demographics
NPI:1750332680
Name:ALIAS, SUSY (MD)
Entity Type:Individual
Prefix:
First Name:SUSY
Middle Name:
Last Name:ALIAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUSY
Other - Middle Name:
Other - Last Name:ALIAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1 JB DRIVE
Mailing Address - Street 2:JEFFERSON BARRACKS
Mailing Address - City:ST, LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63125
Mailing Address - Country:US
Mailing Address - Phone:314-894-6629
Mailing Address - Fax:314-845-5077
Practice Address - Street 1:1 JEFFERSON BARRACKS DR
Practice Address - Street 2:JEFFERSON BARRACKS, VA
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63125-4181
Practice Address - Country:US
Practice Address - Phone:314-894-6629
Practice Address - Fax:314-845-5077
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9895204D00000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Not Answered208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MONONEOtherPHYSICIAN