Provider Demographics
NPI:1477533057
Name:SPHAR, SUSAN (CNM)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:SPHAR
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8600 N. ROUTE 91
Mailing Address - Street 2:SUITE 330
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615
Mailing Address - Country:US
Mailing Address - Phone:309-692-2025
Mailing Address - Fax:309-621-4646
Practice Address - Street 1:5114 N GLEN PARK PLACE RD
Practice Address - Street 2:SUITE 220
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4686
Practice Address - Country:US
Practice Address - Phone:309-692-2025
Practice Address - Fax:309-621-4646
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001042APN176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$01Medicaid
K25149Medicare PIN
D15722Medicare UPIN