Provider Demographics
NPI:1467542530
Name:SHIDONG SU, MD,PC
Entity Type:Organization
Organization Name:SHIDONG SU, MD,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHIDONG
Authorized Official - Middle Name:
Authorized Official - Last Name:SU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-888-1803
Mailing Address - Street 1:13621 ROOSEVELT AVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-5507
Mailing Address - Country:US
Mailing Address - Phone:718-888-1803
Mailing Address - Fax:718-888-0957
Practice Address - Street 1:13621 ROOSEVELT AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-5507
Practice Address - Country:US
Practice Address - Phone:718-888-1803
Practice Address - Fax:718-888-0957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2150432084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05353OtherGHI-MEDICARE
NY02159286Medicaid
NY5P4101Medicare ID - Type Unspecified
NYH41923Medicare UPIN