Provider Demographics
NPI:1295165256
Name:SUSAN C BALBERDE, MD,SC
Entity type:Organization
Organization Name:SUSAN C BALBERDE, MD,SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BALVERDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-525-4511
Mailing Address - Street 1:5524 N PIONEER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60656-1546
Mailing Address - Country:US
Mailing Address - Phone:773-525-4511
Mailing Address - Fax:
Practice Address - Street 1:8330 GRAND AVE
Practice Address - Street 2:
Practice Address - City:RIVER GROVE
Practice Address - State:IL
Practice Address - Zip Code:60171-1435
Practice Address - Country:US
Practice Address - Phone:708-681-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-12
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036046845261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL473280Medicare UPIN