Healthcare Provider Details

I. General information

NPI: 1972641934
Provider Name (Legal Business Name): SUSAN PEARLSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 01/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 N MICHIGAN AVE UNIT B
CHICAGO IL
60611-2826
US

IV. Provider business mailing address

645 N MICHIGAN AVE UNIT B
CHICAGO IL
60611-2826
US

V. Phone/Fax

Practice location:
  • Phone: 773-531-3427
  • Fax:
Mailing address:
  • Phone: 773-531-3427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number036-107647
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036-107647
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number036-107647
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: