=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528025558
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN D URSTEIN MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2006
-----------------------------------------------------
Last Update Date | 01/12/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1328 TWENTY SECOND STREET
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90404-2091
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-582-7089
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 12079
-----------------------------------------------------
City | WESTMINSTER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92685-3852
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-809-3595
-----------------------------------------------------
Fax | 562-468-0347
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | A69962
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------