MEDICARE: DR. SCOTT T SUNDE M.D.

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	79-285	NM

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8HM190	OTHER	NM	MEDICARE PTAN
2	HSZ162	OTHER	NM	MEDICARE PART B
5	HSZ196	OTHER	NM	MEDICARE PART B

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

NPI Number	:	1558367888
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SCOTT T SUNDE M.D.

Provider Business Mailing Address
First Line	:	419 TULANE DR SE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87106-1417
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	801 VASSAR DRIVE NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87106-2725
Country	:	US
Telephone Number	:	505-248-4052
Fax Number	:

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

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	12/15/2010

4588 PARADISE BLVD NW , MEDICARE ADVANTAGE CLINIC
ALBUQUERQUE, NM
87114-4105

Practice Phone: 505-998-1840
Practice Fax: 505-998-1841