1255384277 NPI number — DR. SUSAN LOUISE ALT MD

Table of content: DR. SUSAN LOUISE ALT MD (NPI 1255384277)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255384277 NPI number — DR. SUSAN LOUISE ALT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALT
Provider First Name:
SUSAN
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255384277
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/28/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
ANDERSONVILLE INTERNAL MEDICINE
Provider Second Line Business Mailing Address:
5212 N CLARK ST
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60640
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-500-0246
Provider Business Mailing Address Fax Number:
773-825-8299

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ANDERSONVILLE INTERNAL MEDICINE
Provider Second Line Business Practice Location Address:
5212 N CLARK ST
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-500-0246
Provider Business Practice Location Address Fax Number:
773-825-8299
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  036107356 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 036-107356 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036-107356 . This is a "STAE LICENSE /MEDICAID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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