Provider Demographics
NPI:1811913130
Name:MACKINNON, SUSAN E (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:E
Last Name:MACKINNON
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-362-7388
Mailing Address - Fax:833-301-0853
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:DIV SURG PLASTICS, STE 6G
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-362-7388
Practice Address - Fax:833-301-0853
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1020272086S0105X, 2086S0122X, 207T00000X, 2086S0105X, 2086S0120X, 2086X0206X, 2086S0122X, 2086S0127X, 207T00000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203098306Medicaid
MO203098306Medicaid
MO023010543Medicare PIN
MS120947Medicaid
IL$$$$$$$$$Medicaid