Provider Demographics
NPI:1902802747
Name:PANEK, SUSAN MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARIE
Last Name:PANEK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:FEELY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1905 E 31ST ST
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526-1324
Mailing Address - Country:US
Mailing Address - Phone:708-579-5350
Mailing Address - Fax:
Practice Address - Street 1:1905 E 31ST ST
Practice Address - Street 2:
Practice Address - City:LA GRANGE PARK
Practice Address - State:IL
Practice Address - Zip Code:60526-1324
Practice Address - Country:US
Practice Address - Phone:708-579-5350
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL21609278OtherBLUE CROSS BLUE SHIELD
IL21609278OtherBLUE CROSS BLUE SHIELD
ILD14464Medicare UPIN