MEDICARE: DR. ANDREW BLAKE SUTH PH.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	103TC0700X	Clinical Psychologist		IL

General Provider Information

NPI Number	:	1679663991
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANDREW BLAKE SUTH PH.D.

Provider Business Mailing Address
First Line	:	4451 N PAULINA ST
Second Line	:	APT. 3
City	:	CHICAGO
State	:	IL
Zip	:	60640-5348
Country	:	US
Telephone Number	:	773-907-0364
Fax Number	:

Provider Business Practice Location Address
First Line	:	53 W JACKSON BLVD
Second Line	:	SUITE 602
City	:	CHICAGO
State	:	IL
Zip	:	60604-3606
Country	:	US
Telephone Number	:	773-718-0364
Fax Number	:

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

Provider Enumeration Date	:	10/15/2006
Last Update Date	:	07/08/2007

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