MEDICARE: SUSAN KATHERINE STRUBLE L.M.

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	175M00000X	Lay Midwife	MID-20	ID

General Provider Information

NPI Number	:	1245519495
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN KATHERINE STRUBLE L.M.

Provider Business Mailing Address
First Line	:	1200 CORNWALL RD
Second Line	:
City	:	TROY
State	:	ID
Zip	:	83871-9610
Country	:	US
Telephone Number	:	208-835-4188
Fax Number	:

Provider Business Practice Location Address
First Line	:	1200 CORNWALL RD
Second Line	:
City	:	TROY
State	:	ID
Zip	:	83871-9610
Country	:	US
Telephone Number	:	208-835-4188
Fax Number	:

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

Provider Enumeration Date	:	08/05/2011
Last Update Date	:	08/05/2011

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