MEDICARE: MR. GERARD BALGOS SUSMENA OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	056.007.661	IL

General Provider Information

NPI Number	:	1134362981
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GERARD BALGOS SUSMENA OTR/L

Provider Business Mailing Address
First Line	:	1326 W COLUMBIA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-4326
Country	:	US
Telephone Number	:	773-490-6232
Fax Number	:

Provider Business Practice Location Address
First Line	:	7434 NORTH HERMITAGE AVENUE #3B
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-1639
Country	:	US
Telephone Number	:	847-951-0097
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/09/2009
Last Update Date	:	09/14/2016

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