Provider Demographics
NPI:1487643573
Name:PORTO, SUSAN H (MD)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:H
Last Name:PORTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2600 S MICHIGAN AVE
Mailing Address - Street 2:305
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-2857
Mailing Address - Country:US
Mailing Address - Phone:312-326-4500
Mailing Address - Fax:312-326-1200
Practice Address - Street 1:2600 S MICHIGAN AVE
Practice Address - Street 2:305
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2857
Practice Address - Country:US
Practice Address - Phone:312-326-4500
Practice Address - Fax:312-326-1200
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036074744207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036074744Medicaid
ILK10907Medicare PIN
IL209889Medicare PIN
IL209889/K10907Medicare ID - Type Unspecified
IL036074744Medicaid