Provider Demographics
NPI:1750942231
Name:BANE, SUSAN HAZEL (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:HAZEL
Last Name:BANE
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 1:258 ROXBURY RD
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12534-3612
Mailing Address - Country:US
Mailing Address - Phone:609-432-1898
Mailing Address - Fax:
Practice Address - Street 1:258 ROXBURY RD
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12534-3612
Practice Address - Country:US
Practice Address - Phone:609-432-1898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06170800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine