1558473629 NPI number — DR. SUSAN E MIRKINSON M.D.

Table of content: DR. SUSAN E MIRKINSON M.D. (NPI 1558473629)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558473629 NPI number — DR. SUSAN E MIRKINSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIRKINSON
Provider First Name:
SUSAN
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558473629
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 NORTHERN BLVD
Provider Second Line Business Mailing Address:
SUITE 230
Provider Business Mailing Address City Name:
GREAT NECK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11021-5312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-627-4433
Provider Business Mailing Address Fax Number:
516-627-0552

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 NORTHERN BLVD
Provider Second Line Business Practice Location Address:
SUITE 230
Provider Business Practice Location Address City Name:
GREAT NECK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11021-5312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-627-4433
Provider Business Practice Location Address Fax Number:
516-627-0552
Provider Enumeration Date:
08/31/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  181084-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0170157 . This is a "GHI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0599536 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6C1347 . This is a "HEALTHNET" identifier . This identifiers is of the category "OTHER".
  • Identifier: SM0678AK10 . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 11820P . This is a "HIP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 25992 . This is a "AETNA USHC" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1623355 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 30703 . This is a "VYTRA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: AP433 . This is a "OXFORD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 389551 . This is a "VYTRA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 181084 . This is a "HIP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 181084 . This is a "1199" identifier . This identifiers is of the category "OTHER".
  • Identifier: 78F701 . This is a "BCBS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".