Provider Demographics
NPI:1124038955
Name:ROECKELL MORENO, SUZANNE (DPM)
Entity Type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:
Last Name:ROECKELL MORENO
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 917
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60065-0917
Mailing Address - Country:US
Mailing Address - Phone:847-504-5000
Mailing Address - Fax:847-504-5015
Practice Address - Street 1:40 SKOKIE BLVD STE 520
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-1601
Practice Address - Country:US
Practice Address - Phone:847-504-5000
Practice Address - Fax:847-504-5015
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004685213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004685Medicaid
IL0732240001OtherDMERC FOR PPG
U52993Medicare UPIN
IL016004685Medicaid
480017242Medicare PIN
480017242Medicare PIN
ILL74897Medicare PIN
IL0732240001OtherDMERC FOR PPG