MEDICARE: SUSAN M METTILLE PA-C

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	363A00000X	Physician Assistant		IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	809840	OTHER	IL	MEDICARE - GROUP #
2	208846	OTHER	IL	MEDICARE GROUP #

General Provider Information

NPI Number	:	1790727410
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN M METTILLE PA-C

Provider Business Mailing Address
First Line	:	2805 N KNOXVILLE AVE
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61604-2869
Country	:	US
Telephone Number	:	309-624-9400
Fax Number	:	309-624-2280

Provider Business Practice Location Address
First Line	:	2805 N KNOXVILLE AVE
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61604-2869
Country	:	US
Telephone Number	:	309-624-9400
Fax Number	:	309-624-2280

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

Provider Enumeration Date	:	06/11/2006
Last Update Date	:	02/19/2008

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Directions to “ SUSAN M METTILLE PA-C” Practice Location

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