Provider Demographics
NPI:1558348268
Name:KLEIN, SUSAN M (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:KLEIN
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 1:250 W KENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526
Mailing Address - Country:US
Mailing Address - Phone:217-872-3800
Mailing Address - Fax:217-872-0849
Practice Address - Street 1:250 W KENWOOD AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526
Practice Address - Country:US
Practice Address - Phone:217-872-3800
Practice Address - Fax:217-872-0849
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-084733207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036084733Medicaid
F44955Medicare UPIN
ILL62864Medicare ID - Type Unspecified