Provider Demographics
NPI:1811913585
Name:TATE, SUSAN SB (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:SB
Last Name:TATE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2934 BRECKENRIDGE LN STE 2
Mailing Address - Street 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 STE 2
Practice Address - Street 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
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39021207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyUrogynecology and Reconstructive Pelvic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS000000337344OtherANTHEM
KY50004926OtherPASSPORT PCP
IN200502730Medicaid
KY50015262OtherPASSPORT SPECIALITY
KY50004854OtherPASSPORT SPECIALITY
KY64084148Medicaid
KY000000338030OtherANTHEM
KS000000337344OtherANTHEM