Provider Demographics
NPI:1437158094
Name:RAE, SUSAN (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:RAE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SAWSAN
Other - Middle Name:
Other - Last Name:ALI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:40 MICHELLE WAY
Mailing Address - Street 2:
Mailing Address - City:PINE BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:07058-9446
Mailing Address - Country:US
Mailing Address - Phone:973-812-9091
Mailing Address - Fax:973-237-9053
Practice Address - Street 1:1031 MCBRIDE AVE
Practice Address - Street 2:SUITE 210 D
Practice Address - City:WOODLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:07424-2559
Practice Address - Country:US
Practice Address - Phone:973-812-9091
Practice Address - Fax:973-339-9040
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-17
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06609700207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ01000576801OtherAMERICHOICE HMO
NJ8777209Medicaid
NJ2K4791OtherHEALTHNET HMO
NJ60005903OtherHORIZON NJ HEALTH HMO
NJP00075820OtherRAILROAD MEDICARE
NJ2K4791OtherHEALTHNET HMO
NJ005334Medicare ID - Type Unspecified