Provider Demographics
NPI:1811995566
Name:ALT, SUZANNE E (DO)
Entity type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:E
Last Name:ALT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:SUZANNE
Other - Middle Name:ALT
Other - Last Name:JARBOE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1715 W WORLEY ST STE B
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-1015
Mailing Address - Country:US
Mailing Address - Phone:660-341-3877
Mailing Address - Fax:573-875-4879
Practice Address - Street 1:4230 LINCOLNSHIRE DR STE G
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2189
Practice Address - Country:US
Practice Address - Phone:618-244-6770
Practice Address - Fax:618-244-6772
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9G62208VP0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO173297OtherBLUE SHIELD MO
MO243396934Medicaid
20-3029034OtherEIN
MO955944727Medicare PIN
MO173297OtherBLUE SHIELD MO
P00162247Medicare PIN
20-3029034OtherEIN