MEDICARE: DR. JEANNE SUE VEDDER M.D.

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	207Y00000X	Otolaryngology Physician	25045	WI

General Provider Information

NPI Number	:	1538168752
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEANNE SUE VEDDER M.D.

Provider Business Mailing Address
First Line	:	1400-75 TH STREET
Second Line	:	SUITE 4
City	:	KENOSHA
State	:	WI
Zip	:	53143-1522
Country	:	US
Telephone Number	:	262-657-6577
Fax Number	:	262-657-7844

Provider Business Practice Location Address
First Line	:	1400-75 TH STREET
Second Line	:	SUITE 4
City	:	KENOSHA
State	:	WI
Zip	:	53143-1522
Country	:	US
Telephone Number	:	262-657-6577
Fax Number	:	262-657-7844

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

Provider Enumeration Date	:	07/19/2005
Last Update Date	:	10/11/2007

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