Basic Information
| Provider Information | |||||||||
| NPI: | 1144206145 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BARCLAY | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 W 162ND ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH HOLLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604732003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087302200 | ||||||||
| FaxNumber: | 7082100621 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 W 162ND ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH HOLLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604732003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087302200 | ||||||||
| FaxNumber: | 7082100621 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2005 | ||||||||
| LastUpdateDate: | 12/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 036090785 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 01621679 | 01 | IL | BCBS OF IL | OTHER |