Provider Demographics
NPI:1164617668
Name:SUSAN G BLANK, MD, LLC
Entity Type:Organization
Organization Name:SUSAN G BLANK, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:BLANK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-340-0300
Mailing Address - Street 1:45 BRANT AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1562
Mailing Address - Country:US
Mailing Address - Phone:732-340-0300
Mailing Address - Fax:732-340-9300
Practice Address - Street 1:45 BRANT AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066-1562
Practice Address - Country:US
Practice Address - Phone:732-340-0300
Practice Address - Fax:732-340-9300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-08
Last Update Date:2007-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA051517002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ098725Medicare PIN
NJG63514Medicare UPIN