Individual
MARY T SUPER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
APN
Contact information
Practice address
4440 W 95TH ST, OAK LAWN, IL 60453-2600
(708) 684-8000
Mailing address
4440 W 95TH ST, OAK LAWN, IL 60453-2600
(708) 684-8000
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
209004357
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
203981
GROUP PTAN
IL
01
—
203981003
MEDICARE PTAN
IL
Enumeration date
02/11/2009
Last updated
07/31/2012
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