Healthcare Provider Details

I. General information

NPI: 1932417482
Provider Name (Legal Business Name): SUSAN I GERBER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2010
Last Update Date: 09/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3745 N KEDVALE AVE
CHICAGO IL
60641-3129
US

IV. Provider business mailing address

3745 N KEDVALE AVE
CHICAGO IL
60641-3129
US

V. Phone/Fax

Practice location:
  • Phone: 773-205-7579
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036080140
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number036080140
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: