Basic Information
| Provider Information | |||||||||
| NPI: | 1285722462 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SZIMONISZ | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 155 LAWN AVE | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142071816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168752904 | ||||||||
| FaxNumber: | 7168756717 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 LAWN AVE | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142071816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168752904 | ||||||||
| FaxNumber: | 7168756717 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 02/21/2012 | ||||||||
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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 | 207R00000X | 217784-1 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 217784-1 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 2593959 | 01 | NY | GHI PPO | OTHER | 040426035682 | 01 | NY | FIDELIS | OTHER | 82659 | 01 | NY | GHI HMO | OTHER | 00025144201 | 01 | NY | UNIVERA | OTHER | 000526173001 | 01 | NY | BC/BS | OTHER | 02089201 | 05 | NY | MEDICAID | 0411067 | 01 | NY | INDEPENDENT HEALTH | OTHER | 150523-DL | 01 | NY | PREFERRED CARE | OTHER |