MEDICARE: MS. SUSAN R. WITZ R.D., L.D.

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	133V00000X	Registered Dietitian	164.000255	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	164.000256	OTHER	IL	STATE OF ILLINOIS , DIVISION OF PROFESSIONAL REGULATION, LICENSE
2	636084	OTHER	IL	REGISTERED DIETITIAN, ACADEMY OF NUTRITION AND DIETETICS

General Provider Information

NPI Number	:	1720401391
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSAN R. WITZ R.D., L.D.

Provider Business Mailing Address
First Line	:	1460 N SANDBURG TER
Second Line	:	#301A
City	:	CHICAGO
State	:	IL
Zip	:	60610-8514
Country	:	US
Telephone Number	:	312-944-0855
Fax Number	:	312-944-0855

Provider Business Practice Location Address
First Line	:	1460 N SANDBURG TER
Second Line	:	#301A
City	:	CHICAGO
State	:	IL
Zip	:	60610-8514
Country	:	US
Telephone Number	:	312-944-0855
Fax Number	:	312-944-0855

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

Provider Enumeration Date	:	02/01/2014
Last Update Date	:	02/01/2014

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