Basic Information
| Provider Information | |||||||||
| NPI: | 1376538538 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUTIN | ||||||||
| FirstName: | KENNETH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 462 1ST AVE | ||||||||
| Address2: | ROOM 11N34 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100169196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125626571 | ||||||||
| FaxNumber: | 2112263874 | ||||||||
| Practice Location | |||||||||
| Address1: | 462 1ST AVE | ||||||||
| Address2: | ROOM 11N34 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100169196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125626571 | ||||||||
| FaxNumber: | 2112263874 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LC0200X | 178454 | NY | X | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine | 207L00000X | 178454 | NY | X | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 01953713 | 05 | NY | MEDICAID |