MEDICARE: SUE A AMELL LMT

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	171W00000X	Contractor	014155-1	NY

General Provider Information

NPI Number	:	1487922597
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUE A AMELL LMT

Provider Business Mailing Address
First Line	:	75 LAKEVIEW TER
Second Line	:
City	:	SARANAC LAKE
State	:	NY
Zip	:	12983-2419
Country	:	US
Telephone Number	:	518-524-8787
Fax Number	:	518-354-8047

Provider Business Practice Location Address
First Line	:	75 LAKEVIEW TER
Second Line	:
City	:	SARANAC LAKE
State	:	NY
Zip	:	12983-2419
Country	:	US
Telephone Number	:	518-524-8787
Fax Number	:	518-354-8047

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

Provider Enumeration Date	:	12/02/2011
Last Update Date	:	12/02/2011

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