MEDICARE: DR. SUSAN MARIE LOCKE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	036-073537	IL

General Provider Information

NPI Number	:	1427077841
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN MARIE LOCKE M.D.

Provider Business Mailing Address
First Line	:	7255 W GRAND AVE
Second Line	:
City	:	ELMWOOD PARK
State	:	IL
Zip	:	60707-2028
Country	:	US
Telephone Number	:	708-327-1650
Fax Number	:

Provider Business Practice Location Address
First Line	:	7255 W GRAND AVE
Second Line	:
City	:	ELMWOOD PARK
State	:	IL
Zip	:	60707-2028
Country	:	US
Telephone Number	:	708-327-1650
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	07/28/2015

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