Provider Demographics
NPI:1588678015
Name:KANEHANN, SUSAN A (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:KANEHANN
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 1:3929 MERCY DRIVE
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050
Mailing Address - Country:US
Mailing Address - Phone:815-759-0800
Mailing Address - Fax:815-759-2367
Practice Address - Street 1:3929 MERCY DRIVE
Practice Address - Street 2:
Practice Address - City:MCHENY
Practice Address - State:IL
Practice Address - Zip Code:60050
Practice Address - Country:US
Practice Address - Phone:815-759-0800
Practice Address - Fax:815-759-2367
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036064143207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
C43085Medicare UPIN
ILK53325Medicare PIN
ILK14260Medicare PIN
ILK53325Medicare PIN
IL036064143Medicaid