MEDICARE: SUSAN ELLEN PANES D.O.

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	207K00000X	Allergy & Immunology Physician	183672	NY
2	207KA0200X	Allergy Physician	183672	NY
3	207KI0005X	Clinical & Laboratory Immunology (Allergy & Immunology) Physician	183672	NY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	01454H	OTHER	NY	GHI MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2C0754	OTHER	NY	HEALTHNET
2	5605676	OTHER	NY	AETNA US HEALTHCARE
4	6100677	OTHER	NY	GHI
5	183673	OTHER	NY	HIP
6	0447024006	OTHER	NY	CIGNA
7	1118556	OTHER	NY	UNITED HEALTHCARE
8	1049295	OTHER	NY	FIRST HEALTH
9	90553	OTHER	NY	VYTRA
10	95G741	OTHER	NY	BLUE CROSS BLUE SHIELD
11	ON13091	OTHER	NY	MDNY
12	P1107530	OTHER	NY	OXFORD

General Provider Information

NPI Number	:	1306831706
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN ELLEN PANES D.O.

Provider Business Mailing Address
First Line	:	1 HOLLOW LN
Second Line	:	SUITE 110
City	:	NEW HYDE PARK
State	:	NY
Zip	:	11042-1215
Country	:	US
Telephone Number	:	516-365-6666
Fax Number	:	516-365-2183

Provider Business Practice Location Address
First Line	:	32 VILLAGE SQ
Second Line	:
City	:	GLEN COVE
State	:	NY
Zip	:	11542-2515
Country	:	US
Telephone Number	:	516-676-1111
Fax Number	:	516-676-1366

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

Provider Enumeration Date	:	09/13/2005
Last Update Date	:	07/12/2011

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