MEDICARE: DR. SUSAN WILLARD MD

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	207V00000X	Obstetrics & Gynecology Physician	D0021264	MD

General Provider Information

NPI Number	:	1851459804
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN WILLARD MD

Provider Business Mailing Address
First Line	:	2101 EAST JEFFERSON STREET
Second Line	:	PPQA MEDICARE COMPLIANCE UNIT 6 WEST
City	:	ROCKVILLE
State	:	MD
Zip	:	20852-4908
Country	:	US
Telephone Number	:	301-816-6660
Fax Number	:	301-816-6308

Provider Business Practice Location Address
First Line	:	4920 CAMPBELL BOULEVARD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21236-5916
Country	:	US
Telephone Number	:	410-933-7600
Fax Number	:	410-933-7601

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

Provider Enumeration Date	:	12/04/2006
Last Update Date	:	07/08/2007

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