Basic Information
| Provider Information | |||||||||
| NPI: | 1700877032 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | KIM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1215 VANDALIA ST | ||||||||
| Address2: | |||||||||
| City: | COLLINSVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622344060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183436015 | ||||||||
| FaxNumber: | 6185785759 | ||||||||
| Practice Location | |||||||||
| Address1: | 1215 VANDALIA ST | ||||||||
| Address2: | |||||||||
| City: | COLLINSVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622344060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183436015 | ||||||||
| FaxNumber: | 6185785759 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 05/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 05/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036126550 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | R5E07 | MO | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 036-126550 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | R5E07 | MO | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1700877032 | 05 | MO | MEDICAID |