Provider Demographics
NPI:1568463586
Name:FANAPOUR, SUSAN M ICHELLE (DO)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M ICHELLE
Last Name:FANAPOUR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 HARGER RD STE 408
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1818
Mailing Address - Country:US
Mailing Address - Phone:630-472-8800
Mailing Address - Fax:
Practice Address - Street 1:120 N. OAK STREET
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521
Practice Address - Country:US
Practice Address - Phone:630-856-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361059852085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00236350Medicare PIN
ILI19333Medicare UPIN