1134185556 NPI number — SUSAN M JENSEN M.D.

Table of content: SUSAN M JENSEN M.D. (NPI 1134185556)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134185556 NPI number — SUSAN M JENSEN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JENSEN
Provider First Name:
SUSAN
Provider Middle Name:
M
Provider Name Prefix Text:
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:
1134185556
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 COATES DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOSHEN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10924-6758
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-651-1400
Provider Business Mailing Address Fax Number:
845-651-1512

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2570 ROUTE 9W
Provider Second Line Business Practice Location Address:
STE 4
Provider Business Practice Location Address City Name:
CORNWALL
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12518-1323
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-534-1505
Provider Business Practice Location Address Fax Number:
845-534-1504
Provider Enumeration Date:
04/25/2006

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:  138024 , 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: 30A161L663 . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00510563 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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