Provider Demographics
NPI:1902965163
Name:EMANUELE, SUSAN S (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:S
Last Name:EMANUELE
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 1:1267 E MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2673
Mailing Address - Country:US
Mailing Address - Phone:631-727-7100
Mailing Address - Fax:631-727-6754
Practice Address - Street 1:1267 E MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2673
Practice Address - Country:US
Practice Address - Phone:631-727-7100
Practice Address - Fax:631-727-6754
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY202139207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01677150Medicaid
48J451Medicare ID - Type Unspecified
NY01677150Medicaid
4498240002Medicare NSC