Provider Demographics
NPI:1902965643
Name:RO, SUSIE (MD)
Entity type:Individual
Prefix:
First Name:SUSIE
Middle Name:
Last Name:RO
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 1:2650 RIDGE AVE STE 1223
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 CENTRAL ST STE 880
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1780
Practice Address - Country:US
Practice Address - Phone:847-570-2570
Practice Address - Fax:847-657-5708
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2025-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00048739204R00000X, 2084N0400X, 2084N0600X
IL0361079772084N0400X
MI43015111522084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic Medicine
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1056456Medicaid