Basic Information
| Provider Information | |||||||||
| NPI: | 1417913054 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | SAINT JOHN | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80 MARCUS DR | ||||||||
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| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117474230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313918354 | ||||||||
| FaxNumber: | 6314544163 | ||||||||
| Practice Location | |||||||||
| Address1: | 146-01 45 AVENUE | ||||||||
| Address2: | ROOM 211 | ||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186705775 | ||||||||
| FaxNumber: | 7183216141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2006 | ||||||||
| LastUpdateDate: | 01/22/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 196522 | NY | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 01979973 | 05 | NY | MEDICAID |