Provider Demographics
NPI:1801825633
Name:RACKSON, MARLENE ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:ELLEN
Last Name:RACKSON
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 GUSTAVE L. LEVY PLACE
Mailing Address - Street 2:BOX 1194
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6574
Mailing Address - Country:US
Mailing Address - Phone:212-241-8395
Mailing Address - Fax:212-289-0092
Practice Address - Street 1:1 GUSTAVE L. LEVY PLACE
Practice Address - Street 2:BOX 1194
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6574
Practice Address - Country:US
Practice Address - Phone:212-241-8395
Practice Address - Fax:212-289-0092
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1551512085R0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0205XAllopathic & Osteopathic PhysiciansRadiologyRadiological Physics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01149811Medicaid
NYE03999Medicare UPIN
NY15F721Medicare ID - Type Unspecified