Healthcare Provider Details

I. General information

NPI: 1144206145
Provider Name (Legal Business Name): SUSAN BARCLAY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 12/16/2021
Certification Date: 12/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W 162ND ST
SOUTH HOLLAND IL
60473-2003
US

IV. Provider business mailing address

100 W 162ND ST
SOUTH HOLLAND IL
60473-2003
US

V. Phone/Fax

Practice location:
  • Phone: 708-730-2200
  • Fax: 708-210-0621
Mailing address:
  • Phone: 708-730-2200
  • Fax: 708-210-0621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036090785
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: