MEDICARE: MS. SUSAN CAROLE PORTER MT

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	246QM0706X	Medical Technologist	805	MT

General Provider Information

NPI Number	:	1841546520
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSAN CAROLE PORTER MT

Provider Business Mailing Address
First Line	:	550 6TH AVE NORTH
Second Line	:
City	:	WOLF POINT
State	:	MT
Zip	:	59201
Country	:	US
Telephone Number	:	406-653-5628
Fax Number	:	406-653-1177

Provider Business Practice Location Address
First Line	:	550 SIXTH AV N
Second Line	:
City	:	WOLF POINT
State	:	MT
Zip	:	59201-0729
Country	:	US
Telephone Number	:	406-653-5628
Fax Number	:	406-653-1177

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

Provider Enumeration Date	:	07/31/2012
Last Update Date	:	07/31/2012

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