Basic Information
Provider Information | |||||||||
NPI: | 1376504365 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STRAYER | ||||||||
FirstName: | SUE | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 790129 | ||||||||
Address2: |   | ||||||||
City: | ST LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631790129 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2179642966 | ||||||||
FaxNumber: | 2174643193 | ||||||||
Practice Location | |||||||||
Address1: | 1800 E LAKE SHORE DRIVE | ||||||||
Address2: | ST MARYS-DECATUR | ||||||||
City: | DECATUR | ||||||||
State: | IL | ||||||||
PostalCode: | 625213883 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2174642966 | ||||||||
FaxNumber: | 2174643193 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/29/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X |   | IL | Y |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
ID | Type | State | Issuer | Description | 0360800151 | 05 | IL |   | MEDICAID |