MEDICARE: MS. SUSAN A MEDO MA LP

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	103TB0200X	Cognitive & Behavioral Psychologist	LP3998	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	210D4ME	OTHER	MN	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174686216
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSAN A MEDO MA LP

Provider Business Mailing Address
First Line	:	2530 1ST AVE S
Second Line	:	#301
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-4341
Country	:	US
Telephone Number	:	612-203-8088
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 W FRANKLIN AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-2433
Country	:	US
Telephone Number	:	612-203-8088
Fax Number	:

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

Provider Enumeration Date	:	12/19/2006
Last Update Date	:	10/17/2008

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