Provider Demographics
NPI:1780839407
Name:SUSAN C BALVERDE MD SC
Entity Type:Organization
Organization Name:SUSAN C BALVERDE MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:BALVERDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-544-9690
Mailing Address - Street 1:675 W NORTH AVE
Mailing Address - Street 2:SUITE 410
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-1634
Mailing Address - Country:US
Mailing Address - Phone:708-544-9690
Mailing Address - Fax:
Practice Address - Street 1:675 W NORTH AVE
Practice Address - Street 2:SUITE 410
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1634
Practice Address - Country:US
Practice Address - Phone:708-544-9690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-21
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036046845261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL43280Medicare PIN
ILE34299Medicare UPIN