Provider Demographics
NPI:1154416337
Name:BALTER, SUSAN W (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:W
Last Name:BALTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 S MAPLE AVE
Mailing Address - Street 2:SUITE 5700
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60304
Mailing Address - Country:US
Mailing Address - Phone:708-763-8381
Mailing Address - Fax:708-763-8390
Practice Address - Street 1:610 S MAPLE AVE
Practice Address - Street 2:SUITE 5700
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60304
Practice Address - Country:US
Practice Address - Phone:708-763-8381
Practice Address - Fax:708-763-8390
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
31622989OtherBCBS
IL552880Medicare ID - Type Unspecified
F96520Medicare UPIN