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General NPI Number Information
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NPI Number | 1295165256
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Entity Type | Organization
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Legal Business Name | SUSAN C BALBERDE, MD,SC
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Dates
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Enumeration Date | 11/12/2013
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Last Update Date | 11/12/2013
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Provider Practice Location Address
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Address Line | 8330 GRAND AVE
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City | RIVER GROVE
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State | IL
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Zip | 60171-1435
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Country | US
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Telephone | 708-681-3000
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Fax |
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Provider Business Mailing Address
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Address Line | 5524 N PIONEER AVE
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City | CHICAGO
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State | IL
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Zip | 60656-1546
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Country | US
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Telephone | 773-525-4511
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SUSAN BALVERDE
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Credential | M.D.
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Telephone | 773-525-4511
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 036046845
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License Number State | IL
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