Basic Information
| Provider Information | |||||||||
| NPI: | 1063438646 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | PANNULLO | ||||||||
| FirstName: | SUSAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 575 LEXINGTON AVE | ||||||||
| Address2: | 5THFL. | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100226102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125905152 | ||||||||
| FaxNumber: | 2125907800 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 E 68TH ST | ||||||||
| Address2: | ST 626/BOX 99 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100214870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127464776 | ||||||||
| FaxNumber: | 2127466607 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 09/14/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 176302 | NY | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 01897158 | 05 | NY | MEDICAID |