Provider Demographics
NPI:1497792675
Name:CHANG, SUSANNA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSANNA
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSANNA
Other - Middle Name:
Other - Last Name:BAHNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3001 GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:NORTH CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60064-3048
Mailing Address - Country:US
Mailing Address - Phone:800-393-0865
Mailing Address - Fax:224-610-7568
Practice Address - Street 1:3001 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064-3048
Practice Address - Country:US
Practice Address - Phone:800-393-0865
Practice Address - Fax:224-610-7568
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-112345208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK14967Medicare PIN
ILH68406Medicare UPIN