Provider Demographics
NPI:1376588293
Name:O'MALLEY, SUSAN ANNE (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ANNE
Last Name:O'MALLEY
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 1:101 HOSPITAL RD
Mailing Address - Street 2:BROOKHAVEN MEMORIAL HOSPITAL ER
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4870
Mailing Address - Country:US
Mailing Address - Phone:631-654-7236
Mailing Address - Fax:610-617-6280
Practice Address - Street 1:101 HOSPITAL RD
Practice Address - Street 2:MEDICAL CENTER
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4870
Practice Address - Country:US
Practice Address - Phone:631-687-2953
Practice Address - Fax:610-617-6280
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228389207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I01466Medicare UPIN
NY924V01Medicare ID - Type Unspecified