Provider Demographics
NPI:1023082153
Name:TIDOW-KEBRITCHI, SUSANNE (MD)
Entity type:Individual
Prefix:
First Name:SUSANNE
Middle Name:
Last Name:TIDOW-KEBRITCHI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2160 S 1ST AVE
Mailing Address - Street 2:(9608 ROBERTS RD, HICKORY HILLS, IL. 60457)
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153
Mailing Address - Country:US
Mailing Address - Phone:708-233-5333
Mailing Address - Fax:708-233-5348
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:(9608 ROBERTS RD, HICKORY HILLS, IL. 60457)
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-233-5333
Practice Address - Fax:708-233-5348
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL36108445207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36108445Medicaid
H96995Medicare UPIN
ILK01729Medicare ID - Type Unspecified
IL36108445Medicaid