MEDICARE: MS. HEATHER KATHLEEN MEDER RN

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	163W00000X	Registered Nurse	359542	OH

General Provider Information

NPI Number	:	1073817417
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. HEATHER KATHLEEN MEDER RN

Provider Business Mailing Address
First Line	:	4024 E 53RD ST
Second Line	:
City	:	NEWBURGH HEIGHTS
State	:	OH
Zip	:	44105-4849
Country	:	US
Telephone Number	:	216-210-4931
Fax Number	:

Provider Business Practice Location Address
First Line	:	4024 E 53RD ST
Second Line	:
City	:	NEWBURGH HEIGHTS
State	:	OH
Zip	:	44105-4849
Country	:	US
Telephone Number	:	216-210-4931
Fax Number	:

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

Provider Enumeration Date	:	12/28/2010
Last Update Date	:	12/28/2010

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