Provider Demographics
NPI:1134516735
Name:SUSAN BALDASSARI MD
Entity Type:Organization
Organization Name:SUSAN BALDASSARI MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BALDASSARI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-871-0003
Mailing Address - Street 1:3673 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-1113
Mailing Address - Country:US
Mailing Address - Phone:716-871-0003
Mailing Address - Fax:716-871-0266
Practice Address - Street 1:3673 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-1113
Practice Address - Country:US
Practice Address - Phone:716-871-0003
Practice Address - Fax:716-871-0266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-21
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY167163-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty