Provider Demographics
NPI:1144206145
Name:BARCLAY, SUSAN (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BARCLAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W 162ND ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-2003
Mailing Address - Country:US
Mailing Address - Phone:708-730-2200
Mailing Address - Fax:708-210-0621
Practice Address - Street 1:100 W 162ND ST
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-2003
Practice Address - Country:US
Practice Address - Phone:708-730-2200
Practice Address - Fax:708-210-0621
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036090785208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01621679OtherBCBS OF IL
IL01621679OtherBCBS OF IL
IL200047Medicare ID - Type UnspecifiedGROUP 950150