MEDICARE: DR. SUSAN MADONNA D.O.

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	H59597	MD

General Provider Information

NPI Number	:	1366427940
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN MADONNA D.O.

Provider Business Mailing Address
First Line	:	9649 BELAIR RD
Second Line	:	SECOND FLOOR
City	:	BALTIMORE
State	:	MD
Zip	:	21236-1100
Country	:	US
Telephone Number	:	410-248-2650
Fax Number	:	410-248-2656

Provider Business Practice Location Address
First Line	:	8871 GORMAN RD
Second Line	:	SUITE 300
City	:	LAUREL
State	:	MD
Zip	:	20723-5877
Country	:	US
Telephone Number	:	301-498-3150
Fax Number	:	301-490-2411

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

Provider Enumeration Date	:	12/07/2005
Last Update Date	:	02/04/2011

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