Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0120X | Pediatric Surgery | IL |
NPI | 1053306993 |
---|---|
Provider Name | Susan Luck |
First Address | Chicago, IL 60678-1354 |
Second Address | Chicago, IL 60614-3363 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/09/2005 |
Last Update Date | 25/03/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1627123 | BCBS PROVIDER ID (01) | IL |
D13979 | (02) | IL |