Provider Demographics
NPI:1144313388
Name:COLE, SUSAN J (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:COLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 N KNOXVILLE AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5021
Mailing Address - Country:US
Mailing Address - Phone:309-691-2311
Mailing Address - Fax:309-691-2337
Practice Address - Street 1:5401 N KNOXVILLE AVE STE 105
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5021
Practice Address - Country:US
Practice Address - Phone:309-691-2311
Practice Address - Fax:309-691-2337
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-062798207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036062798Medicaid
ILL70466Medicare ID - Type UnspecifiedINDIVIDUAL
IL809840Medicare ID - Type UnspecifiedGROUP #
D14602Medicare UPIN
IL541730Medicare ID - Type UnspecifiedGROUP
IL036062798Medicaid