Provider Demographics
NPI:1881876803
Name:SUSILA SUBRAMANIAN MD SC
Entity type:Organization
Organization Name:SUSILA SUBRAMANIAN MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSILA
Authorized Official - Middle Name:
Authorized Official - Last Name:SUBRAMANIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-391-9033
Mailing Address - Street 1:150 N RIVER RD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-1272
Mailing Address - Country:US
Mailing Address - Phone:847-391-9033
Mailing Address - Fax:847-391-9177
Practice Address - Street 1:150 N RIVER RD
Practice Address - Street 2:SUITE 240
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-1272
Practice Address - Country:US
Practice Address - Phone:847-391-9033
Practice Address - Fax:847-391-9177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036062896208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036062896Medicaid
IL0001637265OtherBLUE SHIELD