Provider Demographics
NPI:1205252426
Name:SUSAN B TATE MD PA
Entity type:Organization
Organization Name:SUSAN B TATE MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:TATE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-454-7871
Mailing Address - Street 1:2934 BRECKENRIDGE LN
Mailing Address - Street 2:SUITE 2
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-3903
Mailing Address - Country:US
Mailing Address - Phone:502-454-7871
Mailing Address - Fax:502-454-7872
Practice Address - Street 1:2934 BRECKENRIDGE LN
Practice Address - Street 2:SUITE 2
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-3903
Practice Address - Country:US
Practice Address - Phone:502-454-7871
Practice Address - Fax:502-454-7872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-12
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39021207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyUrogynecology and Reconstructive Pelvic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64084148Medicaid
KYK035311Medicare PIN