Provider Demographics
NPI:1063675023
Name:ELRICH, SUSAN MARIA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARIA
Last Name:ELRICH
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:PO BOX 2340
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11969-2340
Mailing Address - Country:US
Mailing Address - Phone:631-283-2430
Mailing Address - Fax:
Practice Address - Street 1:325 MEETING HOUSE LN BLDG 2
Practice Address - Street 2:SUITE 301
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-5087
Practice Address - Country:US
Practice Address - Phone:631-283-4048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0644462084N0400X
WI54401-202084N0400X
NY2489652084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03488382Medicaid
IL036123112OtherSTATE LICENSE
IL214881Medicare Oscar/Certification