Provider Demographics
NPI:1336156884
Name:BOLTON, SUSAN G (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:G
Last Name:BOLTON
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 1:101 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3909
Mailing Address - Country:US
Mailing Address - Phone:217-366-1326
Mailing Address - Fax:217-366-6106
Practice Address - Street 1:1801 W WINDSOR RD
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-6217
Practice Address - Country:US
Practice Address - Phone:217-366-1257
Practice Address - Fax:217-366-6110
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-082604208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036082604 1Medicaid
IL279500OtherMEDICARE GROUP
IL0407950001Medicare NSC
ILK24848Medicare PIN
IL279500OtherMEDICARE GROUP