Provider Demographics
NPI:1598813933
Name:DR. SUSAN M. RADTKE, P.C.
Entity Type:Organization
Organization Name:DR. SUSAN M. RADTKE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:RADTKE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:708-361-5100
Mailing Address - Street 1:11952 S HARLEM AVE
Mailing Address - Street 2:SUITE 200B
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1167
Mailing Address - Country:US
Mailing Address - Phone:708-361-5100
Mailing Address - Fax:708-361-5222
Practice Address - Street 1:11952 S HARLEM AVE
Practice Address - Street 2:SUITE 200B
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1167
Practice Address - Country:US
Practice Address - Phone:708-361-5100
Practice Address - Fax:708-361-5222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1326067331OtherNPI AS INDIV. PROVIDER
IL01632203OtherBLUE CROSS PROVIDER
IL07100632OtherPSYCHOLOGIST LICENSE
IL07100632OtherPSYCHOLOGIST LICENSE