Provider Demographics
NPI:1053330332
Name:EBNER, SUSANA ADELA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSANA
Middle Name:ADELA
Last Name:EBNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 W 168TH ST
Mailing Address - Street 2:BOX 4
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3725
Mailing Address - Country:US
Mailing Address - Phone:212-665-3264
Mailing Address - Fax:
Practice Address - Street 1:1150 ST NICHOLAS AVE
Practice Address - Street 2:2ND FL
Practice Address - City:NY
Practice Address - State:NY
Practice Address - Zip Code:10032-3822
Practice Address - Country:US
Practice Address - Phone:212-851-5494
Practice Address - Fax:212-851-5493
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY226722-1174400000X
NY226722207RE0101X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No174400000XOther Service ProvidersSpecialist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01634371Medicaid
NYF27655Medicare UPIN
NY01634371Medicaid