Provider Demographics
NPI:1346201068
Name:MEROLA-MCCONN, SUSAN L (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:MEROLA-MCCONN
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 1:4117 MEDICAL CENTER DR
Mailing Address - Street 2:POD C
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-6600
Mailing Address - Country:US
Mailing Address - Phone:315-329-4975
Mailing Address - Fax:315-329-4965
Practice Address - Street 1:4117 MEDICAL CENTER DR
Practice Address - Street 2:POD C
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-6600
Practice Address - Country:US
Practice Address - Phone:315-329-4968
Practice Address - Fax:315-329-4970
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY179047207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02508776Medicaid
NYE87597Medicare UPIN
NY39659FMedicare ID - Type Unspecified
NY02508776Medicaid