Basic Information
| Provider Information | |||||||||
| NPI: | 1629119458 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUPRUN | ||||||||
| FirstName: | ULANA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 635 MADISON AVE | ||||||||
| Address2: | 16TH FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100221009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127942500 | ||||||||
| FaxNumber: | 2128793846 | ||||||||
| Practice Location | |||||||||
| Address1: | 635 MADISON AVE | ||||||||
| Address2: | 16TH FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100221009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127942500 | ||||||||
| FaxNumber: | 2128793846 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 174400000X | 200005 | NY | Y | Other Service Providers | Specialist |
No ID Information.