MEDICARE: DR. SUZY BIBAWY M.D.

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	207RA0000X	Adolescent Medicine (Internal Medicine) Physician	210720	NY
2	207RA0401X	Addiction Medicine (Internal Medicine) Physician	210720	NY

General Provider Information

NPI Number	:	1982611125
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUZY BIBAWY M.D.

Provider Business Mailing Address
First Line	:	86 MICHAEL LOOP
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10301-4639
Country	:	US
Telephone Number	:	718-818-5584
Fax Number	:	718-818-6066

Provider Business Practice Location Address
First Line	:	75 VANDERBILT AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10304-2604
Country	:	US
Telephone Number	:	718-818-6000
Fax Number	:

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

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	11/03/2015

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