MEDICARE: MRS. AMY MARIE SURBURG ANP

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	363LA2200X	Adult Health Nurse Practitioner	209.008246	IL

General Provider Information

NPI Number	:	1356649313
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AMY MARIE SURBURG ANP

Provider Business Mailing Address
First Line	:	405 W JACKSON
Second Line	:	PRE-ANESTHESIA DEPARTMENT
City	:	CARBONDALE
State	:	IL
Zip	:	62901-9000
Country	:	US
Telephone Number	:	618-549-0721
Fax Number	:	618-529-0431

Provider Business Practice Location Address
First Line	:	405 W JACKSON
Second Line	:	PRE-ANESTHESIA DEPARTMENT
City	:	CARBONDALE
State	:	IL
Zip	:	62901-9000
Country	:	US
Telephone Number	:	618-549-0721
Fax Number	:	618-529-0431

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

Provider Enumeration Date	:	03/01/2011
Last Update Date	:	03/01/2011

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