Provider Demographics
NPI:1629069901
Name:S MADHUSOODANAN MD PC
Entity Type:Organization
Organization Name:S MADHUSOODANAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT S. MADHUSOODANAN MD PC
Authorized Official - Prefix:
Authorized Official - First Name:SUBRAMONIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MADHUSOODANAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-371-1804
Mailing Address - Street 1:249 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559-1511
Mailing Address - Country:US
Mailing Address - Phone:516-371-1804
Mailing Address - Fax:516-371-1804
Practice Address - Street 1:ST JOHNS EPISCOPAL HOSPITAL 327 BEACH CHANNEL DRIVE
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-1511
Practice Address - Country:US
Practice Address - Phone:718-869-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1389572084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02558818Medicaid
NY02558818Medicaid
B14252Medicare UPIN
NY02981Medicare ID - Type Unspecified