Healthcare Provider Details

I. General information

NPI: 1043246994
Provider Name (Legal Business Name): AMY BLAKE SUSNOW M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY S BLAKE MD

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 07/03/2022
Certification Date: 07/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 HIGHLAND AVE
MADISON WI
53792-2274
US

IV. Provider business mailing address

7974 UW HEALTH CT
MIDDLETON WI
53562-5531
US

V. Phone/Fax

Practice location:
  • Phone: 608-263-6420
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberDR.0058101
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberFE60028232
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWI
# 4
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number56132
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: