Provider Demographics
NPI:1023222908
Name:SUSAN J. EDELSTEIN, M.D., INC.
Entity Type:Organization
Organization Name:SUSAN J. EDELSTEIN, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:EDELSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-659-1300
Mailing Address - Street 1:150 N ROBERTSON BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-2142
Mailing Address - Country:US
Mailing Address - Phone:310-659-1300
Mailing Address - Fax:310-659-4300
Practice Address - Street 1:150 N ROBERTSON BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2142
Practice Address - Country:US
Practice Address - Phone:310-659-1300
Practice Address - Fax:310-659-4300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA0620712080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric GastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18063Medicare ID - Type Unspecified
CAH55211Medicare UPIN