Individual
SUSAN M PENNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
OD
Contact information
Practice address
134 E BLACKHAWK DR, BYRON, IL 61010
(815) 234-2020
(815) 234-7070
Mailing address
134 E BLACKHAWK DR, BYRON, IL 61010-8610
(815) 234-2020
(815) 234-7070
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
046-008009
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
046-008009
OPTOMETRY LICENSE
IL
01
—
410033446
RAILROAD MEDICARE
IL
01
—
4515286
BLUE CROSS BLUE SHIELD
IL
01
—
7184011
BLUE CROSS BLUE SHIELD
IL
01
—
CL7273
RAILROAD MEDICARE GROUP
IL
01
—
L08182
PIN
IL
Enumeration date
01/04/2007
Last updated
06/18/2018
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