Provider Demographics
NPI:1972643633
Name:ELBAUM, SUSAN DEBRA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:DEBRA
Last Name:ELBAUM
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 1:1051 W RAND RD STE 110
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-2315
Mailing Address - Country:US
Mailing Address - Phone:847-618-9292
Mailing Address - Fax:848-618-9294
Practice Address - Street 1:1051 W RAND RD # 110
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-2315
Practice Address - Country:US
Practice Address - Phone:847-618-9292
Practice Address - Fax:847-618-9294
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-104303207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I29299Medicare UPIN
NYRA 6558Medicare ID - Type Unspecified