Provider Demographics
NPI:1558439877
Name:ANANNAB, MIRIAM SUSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MIRIAM
Middle Name:SUSAN
Last Name:ANANNAB
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 1:1 DIAMOND HILL RD
Mailing Address - Street 2:
Mailing Address - City:BERKELEY HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:07922-2104
Mailing Address - Country:US
Mailing Address - Phone:908-273-4300
Mailing Address - Fax:
Practice Address - Street 1:1255 RARITAN RD
Practice Address - Street 2:
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066-1200
Practice Address - Country:US
Practice Address - Phone:848-206-0072
Practice Address - Fax:848-206-0078
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA67554207P00000X
NJ25MA0675500207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8174601Medicaid
NJ8174601Medicaid