Provider Demographics
NPI:1023073145
Name:VOSS, SUSAN STACKELHOUSE
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:STACKELHOUSE
Last Name:VOSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:STACKELHOUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1125 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-5227
Mailing Address - Country:US
Mailing Address - Phone:573-632-5525
Mailing Address - Fax:573-632-5811
Practice Address - Street 1:1125 MADISON ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-5227
Practice Address - Country:US
Practice Address - Phone:573-632-5525
Practice Address - Fax:573-632-5811
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113335208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
440546366OtherUNITED HEALTH CARE
H16641OtherMERCY
1834230OtherFIRST HEALTH
MO204990105OtherMEDICAID
MO207515500OtherMEDICAID
11071OtherCIGNA
MO204990105Medicaid
129170OtherBLUE CROSS BLUE SHIELD
H16641Medicare UPIN