Provider Demographics
NPI:1952331472
Name:NELSON, SUSAN J (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:J
Last Name:NELSON
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 1:716 ELM ST
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:IL
Mailing Address - Zip Code:60093-2556
Mailing Address - Country:US
Mailing Address - Phone:847-501-4040
Mailing Address - Fax:847-501-4075
Practice Address - Street 1:716 ELM ST
Practice Address - Street 2:
Practice Address - City:WINNETKA
Practice Address - State:IL
Practice Address - Zip Code:60093-2556
Practice Address - Country:US
Practice Address - Phone:847-501-4040
Practice Address - Fax:847-501-4075
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG15115Medicare UPIN