Healthcare Provider Details

I. General information

NPI: 1689785040
Provider Name (Legal Business Name): SUSILA SUBRAMANIAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 02/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 N RIVER RD SUITE 240
DES PLAINES IL
60016-1272
US

IV. Provider business mailing address

150 N RIVER RD SUITE 240
DES PLAINES IL
60016-1272
US

V. Phone/Fax

Practice location:
  • Phone: 847-391-9033
  • Fax: 847-391-9177
Mailing address:
  • Phone: 847-391-9033
  • Fax: 847-391-9177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-062896
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: