Healthcare Provider Details

I. General information

NPI: 1386723781
Provider Name (Legal Business Name): GRANT WEI-SIANG SU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2006
Last Update Date: 05/19/2020
Certification Date: 05/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N 8TH ST
SPRINGFIELD IL
62701-1041
US

IV. Provider business mailing address

1025 S 6TH ST
SPRINGFIELD IL
62703-2403
US

V. Phone/Fax

Practice location:
  • Phone: 217-528-7541
  • Fax:
Mailing address:
  • Phone: 217-528-7541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036117645
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: