Provider Demographics
NPI:1952300303
Name:SUSANNE K WOLOSON MD PHD SC
Entity Type:Organization
Organization Name:SUSANNE K WOLOSON MD PHD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIR
Authorized Official - Prefix:
Authorized Official - First Name:SUSANNE
Authorized Official - Middle Name:K
Authorized Official - Last Name:WOLOSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-577-5814
Mailing Address - Street 1:1614 W CENTRAL RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ARLINGTON HTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-2490
Mailing Address - Country:US
Mailing Address - Phone:847-577-5814
Mailing Address - Fax:
Practice Address - Street 1:1614 W CENTRAL RD
Practice Address - Street 2:SUITE 100
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-2490
Practice Address - Country:US
Practice Address - Phone:847-577-5814
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208123Medicare PIN
IL208122Medicare PIN