Provider Demographics
NPI:1053456384
Name:PODELL, SUSAN KAGEN (MS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:KAGEN
Last Name:PODELL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 N MIDLOTHIAN RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-1654
Mailing Address - Country:US
Mailing Address - Phone:847-837-8442
Mailing Address - Fax:847-837-8542
Practice Address - Street 1:560 N MIDLOTHIAN RD
Practice Address - Street 2:SUITE 400
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-1654
Practice Address - Country:US
Practice Address - Phone:847-837-8442
Practice Address - Fax:847-837-8542
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL205822Medicare ID - Type Unspecified