Provider Demographics
NPI:1255384277
Name:ALT, SUSAN LOUISE (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:LOUISE
Last Name:ALT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:ANDERSONVILLE INTERNAL MEDICINE
Mailing Address - Street 2:5212 N CLARK ST
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640
Mailing Address - Country:US
Mailing Address - Phone:773-500-0246
Mailing Address - Fax:773-825-8299
Practice Address - Street 1:ANDERSONVILLE INTERNAL MEDICINE
Practice Address - Street 2:5212 N CLARK ST
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640
Practice Address - Country:US
Practice Address - Phone:773-500-0246
Practice Address - Fax:773-825-8299
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036107356207R00000X
IL036-107356207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-107356OtherSTAE LICENSE /MEDICAID
H75365Medicare UPIN