Provider Demographics
NPI:1265628036
Name:NACK, SUSAN HILLARY (DO)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:HILLARY
Last Name:NACK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:S.
Other - Middle Name:HILLARY
Other - Last Name:NACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:345 E SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2654
Mailing Address - Country:US
Mailing Address - Phone:312-238-1000
Mailing Address - Fax:
Practice Address - Street 1:345 E SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2654
Practice Address - Country:US
Practice Address - Phone:312-238-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-14
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN020-03652A208100000X
IL036-123319208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN2009822690Medicaid
IL036123319-1Medicaid
IL572710009Medicare PIN
IN2009822690Medicaid
IN259780DMedicare PIN
IL573230010Medicare PIN