Provider Demographics
NPI:1447390653
Name:SUZANNE M GREIDER,MD
Entity type:Organization
Organization Name:SUZANNE M GREIDER,MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:GREIDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-869-5480
Mailing Address - Street 1:800 AUSTIN ST
Mailing Address - Street 2:311 WEST
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-3439
Mailing Address - Country:US
Mailing Address - Phone:847-869-5480
Mailing Address - Fax:847-869-5487
Practice Address - Street 1:800 AUSTIN ST
Practice Address - Street 2:311 WEST
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-3439
Practice Address - Country:US
Practice Address - Phone:847-869-5480
Practice Address - Fax:847-869-5487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036065627207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036065627Medicaid
IL732170Medicare ID - Type Unspecified
IL036065627Medicaid