Provider Demographics
NPI:1902825771
Name:LIEBOVITZ, SUSAN G (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:G
Last Name:LIEBOVITZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 W. HIGGINS ROAD
Mailing Address - Street 2:SUITE 1040
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60169
Mailing Address - Country:US
Mailing Address - Phone:847-884-8096
Mailing Address - Fax:847-884-8125
Practice Address - Street 1:2500 W. HIGGINS ROAD
Practice Address - Street 2:SUITE 1040
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60169
Practice Address - Country:US
Practice Address - Phone:847-884-8096
Practice Address - Fax:847-884-8125
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC45505Medicare UPIN
ILL03463Medicare PIN
IL677490Medicare ID - Type UnspecifiedGROUP #