MEDICARE: DR. BRIAN DIEVENDORF SUSI 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	207RC0000X	Cardiovascular Disease Physician	25MA09314200	NJ

General Provider Information

NPI Number	:	1922079862
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIAN DIEVENDORF SUSI MD

Provider Business Mailing Address
First Line	:	209 MANHATTAN AVE
Second Line	:	APC C
City	:	UNION CITY
State	:	NJ
Zip	:	07087-5204
Country	:	US
Telephone Number	:	917-232-2458
Fax Number	:

Provider Business Practice Location Address
First Line	:	209 MANHATTAN AVE
Second Line	:	APC C
City	:	UNION CITY
State	:	NJ
Zip	:	07087-5204
Country	:	US
Telephone Number	:	917-232-2458
Fax Number	:

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

Provider Enumeration Date	:	01/30/2006
Last Update Date	:	01/14/2026

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