Provider Demographics
NPI:1285994616
Name:CHACKO, ANSU SUSAN (PT)
Entity type:Individual
Prefix:
First Name:ANSU
Middle Name:SUSAN
Last Name:CHACKO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14014 MARSH PIKE
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-1638
Mailing Address - Country:US
Mailing Address - Phone:301-864-2333
Mailing Address - Fax:877-828-2060
Practice Address - Street 1:176 GRAND ST
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10601-4803
Practice Address - Country:US
Practice Address - Phone:914-328-6080
Practice Address - Fax:914-328-6081
Is Sole Proprietor?:No
Enumeration Date:2012-05-18
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034937225100000X
MD25062225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1447657507OtherNPI
MD463684374OtherTAX ID
MD4374045-00Medicaid
NYA400073232Medicare PIN
MD463684374OtherTAX ID
MD4374045-00Medicaid
NYA400069822Medicare PIN
NYA400069821Medicare PIN