Healthcare Provider Details

I. General information

NPI: 1407985682
Provider Name (Legal Business Name): SUSAN E WARD CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

966 W 21ST ST
CHICAGO IL
60608-4511
US

IV. Provider business mailing address

9765 S WOOD ST
CHICAGO IL
60643-1620
US

V. Phone/Fax

Practice location:
  • Phone: 312-829-6030
  • Fax: 312-829-6822
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number309-001206
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: