Provider Demographics
NPI:1396833471
Name:TRAVERS CONCANNON, EILEEN M (MD)
Entity Type:Individual
Prefix:DR
First Name:EILEEN
Middle Name:M
Last Name:TRAVERS CONCANNON
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 1:560 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-5013
Mailing Address - Country:US
Mailing Address - Phone:516-933-2200
Mailing Address - Fax:
Practice Address - Street 1:34 WILLOW DR
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:NJ
Practice Address - Zip Code:07930-2812
Practice Address - Country:US
Practice Address - Phone:908-625-5187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA037663002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0291404Medicaid
NJ575763Medicare ID - Type Unspecified
NJE75311Medicare UPIN