MEDICARE: DR. SUSAN K. ROBERTS 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	207Q00000X	Family Medicine Physician	6397A	WY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	W24224	OTHER	WY	MEDICARE PTAN

General Provider Information

NPI Number	:	1063417954
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN K. ROBERTS M.D.

Provider Business Mailing Address
First Line	:	1842 SUGARLAND DR
Second Line	:	SUITE 101
City	:	SHERIDAN
State	:	WY
Zip	:	82801-5719
Country	:	US
Telephone Number	:	307-673-4960
Fax Number	:	307-673-4951

Provider Business Practice Location Address
First Line	:	1842 SUGARLAND DR
Second Line	:	SUITE 101
City	:	SHERIDAN
State	:	WY
Zip	:	82801-5719
Country	:	US
Telephone Number	:	307-673-4960
Fax Number	:	307-673-4951

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

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	12/01/2011

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