Provider Demographics
NPI:1447257571
Name:BURKHART, SUSAN MARY (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARY
Last Name:BURKHART
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:P.O. BOX 1027
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65102-1027
Mailing Address - Country:US
Mailing Address - Phone:573-761-7246
Mailing Address - Fax:573-761-6947
Practice Address - Street 1:801 KIDWELL DRIVE
Practice Address - Street 2:ST MARY'S CLINIC
Practice Address - City:VERSAILLES
Practice Address - State:MO
Practice Address - Zip Code:65084
Practice Address - Country:US
Practice Address - Phone:573-378-5454
Practice Address - Fax:573-378-5055
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO104938208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO33968017OtherBCBS
MO207903022Medicaid
MO2007903022Medicaid
MO853019OtherFRIST HEALTH
MO32329OtherFAMILY HEALTH PARTNERS
MO5487OtherHEALTH CARE USA
MO131810004Medicare PIN
MOE28804Medicare UPIN
MO207903022Medicaid