MEDICARE: DR. SUSAN A DEMUTH M.D.

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	208000000X	Pediatrics Physician	0101037909	VA

General Provider Information

NPI Number	:	1730179284
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN A DEMUTH M.D.

Provider Business Mailing Address
First Line	:	KIMBROUGH AMBULATORY CARE CENTER
Second Line	:	ATTN: MCXR-CR 2480 LLEWELLYN AVE.
City	:	FT. MEADE
State	:	MD
Zip	:	20755
Country	:	US
Telephone Number	:	301-677-8270
Fax Number	:	301-677-8176

Provider Business Practice Location Address
First Line	:	2480 LLEWELLYN AVE
Second Line	:
City	:	FT MEADE
State	:	MD
Zip	:	20755-5800
Country	:	US
Telephone Number	:	301-677-8641
Fax Number	:	301-677-8485

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

Provider Enumeration Date	:	10/26/2005
Last Update Date	:	07/08/2007

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