Provider Demographics
NPI:1992837140
Name:GLASSMAN, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:GLASSMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 RAYMOND AVE
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:10977-6307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16 RAYMOND AVE
Practice Address - Street 2:
Practice Address - City:CHESTNUT RIDGE
Practice Address - State:NY
Practice Address - Zip Code:10977-6307
Practice Address - Country:US
Practice Address - Phone:845-426-6746
Practice Address - Fax:845-356-8705
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002672-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY040426011791OtherFIDELIS CARE