Basic Information
| Provider Information | |||||||||
| NPI: | 1043266224 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STAUDT | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1912 FREMONT AVE S | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554032932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147041929 | ||||||||
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| Practice Location | |||||||||
| Address1: | B515 MAYO MEMORIAL BUILDING | ||||||||
| Address2: | 420 DELAWARE ST SE | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126249990 | ||||||||
| FaxNumber: | 6126262363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 10/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP3000X | 43128 | WI | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology | 207L00000X | 43128 | WI | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP3000X | 66314 | MN | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1043266224 | 05 | WI | MEDICAID | 006006261K | 01 | HUMANA | OTHER |