Basic Information
| Provider Information | |||||||||
| NPI: | 1972616746 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | SUICH | ||||||||
| FirstName: | DENNIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 670 MASON RIDGE CENTER DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631418573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149967644 | ||||||||
| FaxNumber: | 3149967658 | ||||||||
| Practice Location | |||||||||
| Address1: | 1605 E BROADWAY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652018023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738157119 | ||||||||
| FaxNumber: | 5738157116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 10/27/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 101237 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 203369905 | 05 | MO | MEDICAID |