MEDICARE: SUSAN MARY PRIEM P.T.

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	225100000X	Physical Therapist	4097	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	348G0PR	OTHER	MN	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1144205840
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN MARY PRIEM P.T.

Provider Business Mailing Address
First Line	:	5201 CHOWEN AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55410-2121
Country	:	US
Telephone Number	:	612-805-2741
Fax Number	:	612-922-9177

Provider Business Practice Location Address
First Line	:	5201 CHOWEN AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55410-2121
Country	:	US
Telephone Number	:	612-805-2741
Fax Number	:	612-922-9177

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

Provider Enumeration Date	:	12/14/2005
Last Update Date	:	07/08/2007

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