MEDICARE: SUSAN B TATE MD PA

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	207VF0040X	Urogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician	39021	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205252426
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUSAN B TATE MD PA

Provider Business Mailing Address
First Line	:	2934 BRECKENRIDGE LN
Second Line	:	SUITE 2
City	:	LOUISVILLE
State	:	KY
Zip	:	40220-3903
Country	:	US
Telephone Number	:	502-454-7871
Fax Number	:	502-454-7872

Provider Business Practice Location Address
First Line	:	2934 BRECKENRIDGE LN
Second Line	:	SUITE 2
City	:	LOUISVILLE
State	:	KY
Zip	:	40220-3903
Country	:	US
Telephone Number	:	502-454-7871
Fax Number	:	502-454-7872

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SUSAN B TATE
Credential	:	MD
Telephone Number	:	502-454-7871

Provider Enumeration Date	:	03/12/2014
Last Update Date	:	03/12/2014

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Directions to “SUSAN B TATE MD PA ” Practice Location

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