Provider Demographics
NPI:1700924222
Name:ATHLETIC AND INDUSTRIAL MEDICINE
Entity type:Organization
Organization Name:ATHLETIC AND INDUSTRIAL MEDICINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:FRANCES
Authorized Official - Last Name:SUSEDIK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:815-754-1122
Mailing Address - Street 1:1985 DEKALB AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3107
Mailing Address - Country:US
Mailing Address - Phone:815-754-1122
Mailing Address - Fax:815-787-3678
Practice Address - Street 1:1985 DEKALB AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3107
Practice Address - Country:US
Practice Address - Phone:815-754-1122
Practice Address - Fax:815-787-3678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036079869261QU0200X
IL036081304261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE71843Medicare UPIN
IL211332Medicare PIN
ILD95482Medicare UPIN