MEDICARE: SUSAN B TATE MD PSC

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	207V00000X	Obstetrics & Gynecology Physician

General Provider Information

NPI Number	:	1437531837
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUSAN B TATE MD PSC

Provider Business Mailing Address
First Line	:	2934 BRECKENRIDGE LN STE 2
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40220-3903
Country	:	US
Telephone Number	:	502-454-7871
Fax Number	:	502-454-7872

Provider Business Practice Location Address
First Line	:	2934 BRECKENRIDGE LN STE 2
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40220-3903
Country	:	US
Telephone Number	:	502-454-7871
Fax Number	:	502-454-7872

Authorized Official
Title or Position	:	OWNER
Name	:	SUSAN TATE
Credential	:	MD
Telephone Number	:	502-454-7871

Provider Enumeration Date	:	06/22/2015
Last Update Date	:	07/17/2015

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