MEDICARE: S MADHUSOODANAN MD PC

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	2084P0800X	Psychiatry Physician	138957	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629069901
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	S MADHUSOODANAN MD PC

Provider Business Mailing Address
First Line	:	249 BROADWAY
Second Line	:
City	:	LAWRENCE
State	:	NY
Zip	:	11559-1511
Country	:	US
Telephone Number	:	516-371-1804
Fax Number	:	516-371-1804

Provider Business Practice Location Address
First Line	:	ST JOHNS EPISCOPAL HOSPITAL 327 BEACH CHANNEL DRIVE
Second Line	:
City	:	FAR ROCKAWAY
State	:	NY
Zip	:	11691-1511
Country	:	US
Telephone Number	:	718-869-7000
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT S. MADHUSOODANAN MD PC
Name	:	SUBRAMONIAM MADHUSOODANAN
Credential	:	MD
Telephone Number	:	516-371-1804

Provider Enumeration Date	:	11/04/2005
Last Update Date	:	03/17/2018

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