Provider Demographics
NPI:1265518179
Name:NOBILSKI, MARY SUSAN (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:SUSAN
Last Name:NOBILSKI
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 1:5 GANSEVOORT ST.
Mailing Address - Street 2:P.O. BOX 366
Mailing Address - City:BATH
Mailing Address - State:NY
Mailing Address - Zip Code:14810
Mailing Address - Country:US
Mailing Address - Phone:607-776-6577
Mailing Address - Fax:
Practice Address - Street 1:115 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14810-1508
Practice Address - Country:US
Practice Address - Phone:607-776-6577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1781142084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00178114Medicaid
NYRA2125Medicare ID - Type Unspecified