Basic Information
| Provider Information | |||||||||
| NPI: | 1174507594 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DESANTIS | ||||||||
| FirstName: | MARYANNE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 EDGEWATER ST | ||||||||
| Address2: | 6TH FL. PAYER RELATION | ||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103054900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182261008 | ||||||||
| FaxNumber: | 7182261039 | ||||||||
| Practice Location | |||||||||
| Address1: | 375 SEGUINE AVE | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103093932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182262440 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2005 | ||||||||
| LastUpdateDate: | 08/01/2008 | ||||||||
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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 | 2084P0800X | 190585 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084F0202X | 190585 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Forensic Psychiatry | 2084P0802X | 190585 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | P00602172 | 01 | NY | RAILROAD MEDICARE | OTHER | DN0541 | 01 | NY | RAILROAD MEDICARE GRP # | OTHER | 260049316 | 01 | RAILROAD MEDICARE | OTHER | 02106196 | 05 | NY | MEDICAID |