Provider Demographics
NPI:1598827628
Name:CAMPANILE, SUSAN P (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:P
Last Name:CAMPANILE
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 1:630 W 168TH ST # 4
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3725
Mailing Address - Country:US
Mailing Address - Phone:212-305-9817
Mailing Address - Fax:914-593-7881
Practice Address - Street 1:3 MICHAEL FREY DRIVE
Practice Address - Street 2:
Practice Address - City:EASTCHESTER
Practice Address - State:NY
Practice Address - Zip Code:10709-5059
Practice Address - Country:US
Practice Address - Phone:914-337-3500
Practice Address - Fax:914-593-7881
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206244207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00951939OtherRAILROAD MEDICARE PTAN
NY00506318Medicaid
NYA100000178OtherMEDICARE GROUP PTAN
NYA400061892Medicare PIN
G67515Medicare UPIN
7T2631Medicare ID - Type Unspecified