Provider Demographics
NPI:1063471209
Name:GANNON, SUSAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:M
Last Name:GANNON
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 1:455 PATROON CREEK BLVD.
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12206
Mailing Address - Country:US
Mailing Address - Phone:518-438-0505
Mailing Address - Fax:518-438-4517
Practice Address - Street 1:455 PATROON CREEK BLVD.
Practice Address - Street 2:SUITE 101
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12206
Practice Address - Country:US
Practice Address - Phone:518-438-0505
Practice Address - Fax:518-438-4517
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY234913-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02685936Medicaid
NY02685936Medicaid
NYRA7602Medicare ID - Type Unspecified