MEDICARE: SUSAN RAYMUNDO MD

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	2080A0000X	Pediatric Adolescent Medicine Physician	4301034153	MI

General Provider Information

NPI Number	:	1457761066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN RAYMUNDO MD

Provider Business Mailing Address
First Line	:	209 CHESTNUT CIR
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48304-2105
Country	:	US
Telephone Number	:	248-540-7482
Fax Number	:	248-540-6086

Provider Business Practice Location Address
First Line	:	209 CHESTNUT CIR
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48304-2105
Country	:	US
Telephone Number	:	248-540-7482
Fax Number	:	248-540-6086

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

Provider Enumeration Date	:	05/05/2014
Last Update Date	:	05/05/2014

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