=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770644007
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN SPATER-ZIMMERMAN M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 MAIN ST
-----------------------------------------------------
City | PORT WASHINGTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11050-2849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-707-7595
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 32 GLAMFORD AVE.
-----------------------------------------------------
City | PORT WASHINGTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11050-2437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-767-7021
-----------------------------------------------------
Fax | 516-767-7021
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 161243
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------