Individual
DR. SUSAN G. BOLTON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
1801 W WINDSOR RD, CHAMPAIGN, IL 61822-6217
(217) 366-1257
(217) 366-6110
Mailing address
101 W UNIVERSITY AVE, CHAMPAIGN, IL 61820-3909
(217) 366-1326
(217) 366-6106
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
036-082604
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036082604 1
—
IL
01
—
279500
MEDICARE GROUP
IL
Enumeration date
08/01/2006
Last updated
01/05/2022
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