1295757177 NPI number — DR. SUANNE GARBER MALLENBAUM MD, PHD

Table of content: DR. SUANNE GARBER MALLENBAUM MD, PHD (NPI 1295757177)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295757177 NPI number — DR. SUANNE GARBER MALLENBAUM MD, PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALLENBAUM
Provider First Name:
SUANNE
Provider Middle Name:
GARBER
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD, PHD
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:
1295757177
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 318H
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCARSDALE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10583-8818
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-382-6308
Provider Business Mailing Address Fax Number:
914-381-6308

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 WEST AVE
Provider Second Line Business Practice Location Address:
SUITE 215
Provider Business Practice Location Address City Name:
LARCHMONT
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10538-2470
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-834-4379
Provider Business Practice Location Address Fax Number:
914-381-2633
Provider Enumeration Date:
07/23/2006

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: 2084P0005X , with the licence number:  183699 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 2084P0804X , with the licence number: 183699 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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





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