Basic Information
| Provider Information | |||||||||
| NPI: | 1073697587 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRUNDAGE | ||||||||
| FirstName: | SUSAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 530 1ST AVE # HCC 6C | ||||||||
| Address2: | DEPARTMENT OF SURGERY | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100166402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122637302 | ||||||||
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| Practice Location | |||||||||
| Address1: | 530 1ST AVE # HCC6C | ||||||||
| Address2: | DEPARTMENT OF SURGERY | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100166402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122637302 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 12/23/2011 | ||||||||
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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 | 208600000X | A52714 | CA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00A527140 | 05 | CA | MEDICAID |