Provider Demographics
NPI:1730274028
Name:RUNDELL, SUSAN G (RPT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:G
Last Name:RUNDELL
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 310
Mailing Address - Street 2:
Mailing Address - City:OLD FORGE
Mailing Address - State:NY
Mailing Address - Zip Code:13420-0310
Mailing Address - Country:US
Mailing Address - Phone:315-369-3086
Mailing Address - Fax:315-369-3086
Practice Address - Street 1:183 PARK AVE
Practice Address - Street 2:
Practice Address - City:OLD FORGE
Practice Address - State:NY
Practice Address - Zip Code:13420-0310
Practice Address - Country:US
Practice Address - Phone:315-369-3086
Practice Address - Fax:315-369-3086
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007287225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01280051Medicaid
NYCC1709Medicare ID - Type Unspecified
NY01280051Medicaid