Provider Demographics
NPI:1235345539
Name:AL GHARAIBEH, SUZAN (MD)
Entity Type:Individual
Prefix:
First Name:SUZAN
Middle Name:
Last Name:AL GHARAIBEH
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 1:701 N 1ST ST
Mailing Address - Street 2:PO BOX 19639
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9639
Mailing Address - Country:US
Mailing Address - Phone:217-545-7578
Mailing Address - Fax:217-545-1884
Practice Address - Street 1:751 N RUTLEDGE ST
Practice Address - Street 2:RM 2300
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702
Practice Address - Country:US
Practice Address - Phone:217-545-3821
Practice Address - Fax:217-545-4735
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-113428207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036113428Medicaid
ILK38714Medicare PIN