1720089444 NPI number — DR. SUSAN K GIBBONS MD

Table of content: DR. SUSAN K GIBBONS MD (NPI 1720089444)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720089444 NPI number — DR. SUSAN K GIBBONS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GIBBONS
Provider First Name:
SUSAN
Provider Middle Name:
K
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1720089444
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8510
Provider Second Line Business Mailing Address:
SUSAN K GIBBONS MD PLLC
Provider Business Mailing Address City Name:
ALBANY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12208-0510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-262-3368
Provider Business Mailing Address Fax Number:
518-262-3399

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
43 NEW SCOTLAND AVE
Provider Second Line Business Practice Location Address:
DEPT RADIATION ONCOLOGY
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12208-3412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-262-3368
Provider Business Practice Location Address Fax Number:
518-262-3399
Provider Enumeration Date:
08/03/2005

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: 2085R0001X , with the licence number:  71830 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0001X , with the licence number: 192535 , 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)