Basic Information
| Provider Information | |||||||||
| NPI: | 1417178575 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUSMAN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | H. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43 KENSICO DRIVE | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | MOUNT KISCO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105491009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146668866 | ||||||||
| FaxNumber: | 9146666777 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 N. MIDLAND AVENUE | ||||||||
| Address2: | NYACK HOSPITAL | ||||||||
| City: | NYACK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453482862 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 10/30/2008 | ||||||||
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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 | 207L00000X | 233039 | NY | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 02888177 | 05 | NY | MEDICAID | P00608762 | 01 | NY | RAIL ROAD MEDICARE | OTHER |