Healthcare Provider Details

I. General information

NPI: 1295741601
Provider Name (Legal Business Name): SUSAN EILEEN ZUCKERMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN EILEEN FANNON MD

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1975 LIN LOR LN SUITE 195
ELGIN IL
60123-4902
US

IV. Provider business mailing address

1975 LIN LOR LN SUITE 195
ELGIN IL
60123-4902
US

V. Phone/Fax

Practice location:
  • Phone: 847-468-1511
  • Fax: 847-468-1555
Mailing address:
  • Phone: 847-468-1511
  • Fax: 847-468-1555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number036-104964
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: