Basic Information
| Provider Information | |||||||||
| NPI: | 1578534889 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOULD | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 403 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | DIXON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610213116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152855552 | ||||||||
| FaxNumber: | 8152855865 | ||||||||
| Practice Location | |||||||||
| Address1: | 403 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | DIXON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610213116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152855552 | ||||||||
| FaxNumber: | 8152855865 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 10/28/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 036067012 | IL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036067012 | 05 | IL | MEDICAID |