Healthcare Provider Details

I. General information

NPI: 1205252426
Provider Name (Legal Business Name): SUSAN B TATE MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2014
Last Update Date: 03/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2934 BRECKENRIDGE LN SUITE 2
LOUISVILLE KY
40220-3903
US

IV. Provider business mailing address

2934 BRECKENRIDGE LN SUITE 2
LOUISVILLE KY
40220-3903
US

V. Phone/Fax

Practice location:
  • Phone: 502-454-7871
  • Fax: 502-454-7872
Mailing address:
  • Phone: 502-454-7871
  • Fax: 502-454-7872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number39021
License Number StateKY

VIII. Authorized Official

Name: DR. SUSAN B TATE
Title or Position: OWNER
Credential: MD
Phone: 502-454-7871