MEDICARE: DR. SUSAN LYNNE GONNELLA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	176885	NY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	53903	OTHER	CT	NON-MEDICARE
2	MD453535	OTHER	PA	NON-MEDICARE
5	4301109059	OTHER	MI	NON-MEDICARE
6	MD174379	OTHER	OR	NON-MEDICARE
7	ME122217	OTHER	FL	NON-MEDICARE
8	0101257922	OTHER	VA	NON-MEDICARE
10	D008371	OTHER	MD	NON-MEDICARE
11	MD043243	OTHER	DC	NON-MEDICARE
12	036.136110	OTHER	IL	NON-MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	176885	OTHER	NY	LICENSE
4	50870	OTHER	NJ	NJ MEDICAL LICENSE
9	C130434	OTHER	CA	CA MEDICAL LICENSE

General Provider Information

NPI Number	:	1013102227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN LYNNE GONNELLA MD

Provider Business Mailing Address
First Line	:	25 W 45TH ST FL 11
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10036-4902
Country	:	US
Telephone Number	:	866-271-3589
Fax Number	:	315-692-0544

Provider Business Practice Location Address
First Line	:	25 W 45TH ST FL 11
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10036-4902
Country	:	US
Telephone Number	:	866-271-3589
Fax Number	:	315-692-0544

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/11/2007
Last Update Date	:	01/23/2024

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