Provider Demographics
NPI:1235512468
Name:BLACK, SUZANNE MARIE (NP)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:MARIE
Last Name:BLACK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 LEXINGTON AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075-0309
Mailing Address - Country:US
Mailing Address - Phone:212-434-4350
Mailing Address - Fax:212-434-4408
Practice Address - Street 1:1120 LEXINGTON AVE FL 2
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-0309
Practice Address - Country:US
Practice Address - Phone:212-434-4350
Practice Address - Fax:212-434-4408
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF340300363LF0000X
NY686557163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00695941Medicaid
NY331944Medicare Oscar/Certification
NY331946Medicare Oscar/Certification
NY331947Medicare Oscar/Certification
NY331978Medicare Oscar/Certification
NY331009Medicare Oscar/Certification
NYW6L111Medicare Oscar/Certification
NY331058Medicare Oscar/Certification
NYG100000410Medicare Oscar/Certification
NY331945Medicare Oscar/Certification
NY00695941Medicaid
NY331043Medicare Oscar/Certification
NY331952Medicare Oscar/Certification
NY331954Medicare Oscar/Certification