Provider Demographics
NPI:1295741601
Name:ZUCKERMAN, SUSAN EILEEN (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:EILEEN
Last Name:ZUCKERMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:EILEEN
Other - Last Name:FANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1975 LIN LOR LN
Mailing Address - Street 2:SUITE 195
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-4902
Mailing Address - Country:US
Mailing Address - Phone:847-468-1511
Mailing Address - Fax:847-468-1555
Practice Address - Street 1:1975 LIN LOR LN
Practice Address - Street 2:SUITE 195
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-4902
Practice Address - Country:US
Practice Address - Phone:847-468-1511
Practice Address - Fax:847-468-1555
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-104964208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036104964Medicaid
ILIL3248Medicare PIN
H37298Medicare UPIN