Basic Information
| Provider Information | |||||||||
| NPI: | 1265628036 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NACK | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | HILLARY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NACK | ||||||||
| OtherFirstName: | S. | ||||||||
| OtherMiddleName: | HILLARY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 345 E SUPERIOR ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122381000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 345 E SUPERIOR ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122381000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2007 | ||||||||
| LastUpdateDate: | 11/08/2010 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 020-03652A | IN | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | 036-123319 | IL | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 2009822690 | 05 | IN | MEDICAID | 036123319-1 | 05 | IL | MEDICAID |