Basic Information
| Provider Information | |||||||||
| NPI: | 1306471768 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUSS | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | RICHARD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 180 HARVESTER DR STE 110 | ||||||||
| Address2: | |||||||||
| City: | BURR RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605276686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737021150 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5841 S MARYLAND AVE # MC6040 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606371443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737026337 | ||||||||
| FaxNumber: | 7736022140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2020 | ||||||||
| LastUpdateDate: | 05/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208600000X | 125077750 | IL | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.