Provider Demographics
NPI:1053649418
Name:SURLYN, COLLEEN STEPHANIE (MD)
Entity Type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:STEPHANIE
Last Name:SURLYN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:COLLEEN
Other - Middle Name:STEPHANIE
Other - Last Name:LYNCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:64 BLEECKER ST # 151
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10012-2410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:632 BROADWAY PH
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-2614
Practice Address - Country:US
Practice Address - Phone:347-933-6246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-24
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY270474207RA0401X
390200000X
NY270474-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program