MEDICARE: PAUL ERWIN SUSMAN PHD

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	103TC0700X	Clinical Psychologist		IL

General Provider Information

NPI Number	:	1720059157
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL ERWIN SUSMAN PHD

Provider Business Mailing Address
First Line	:	8649 SAINT LOUIS AVE
Second Line	:	SUITE 2
City	:	SKOKIE
State	:	IL
Zip	:	60076-2315
Country	:	US
Telephone Number	:	847-675-1637
Fax Number	:

Provider Business Practice Location Address
First Line	:	GREAT LAKES NAVAL BASE
Second Line	:	NORTH CHICAGO
City	:	NORTH CHICAGO
State	:	IL
Zip	:	60088
Country	:	US
Telephone Number	:	847-688-7406
Fax Number	:

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

Provider Enumeration Date	:	02/01/2006
Last Update Date	:	07/08/2007

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