Provider Demographics
NPI:1407860935
Name:SUDTELGTE, CAROL (CNM)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:SUDTELGTE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:834 CHESTNUT ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5127
Mailing Address - Country:US
Mailing Address - Phone:215-955-5000
Mailing Address - Fax:215-955-5041
Practice Address - Street 1:834 CHESTNUT ST
Practice Address - Street 2:SUITE 400
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5127
Practice Address - Country:US
Practice Address - Phone:215-955-5000
Practice Address - Fax:215-955-5041
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMW008307L367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014039670009Medicaid
R97593Medicare UPIN
PA574287HDMedicare ID - Type Unspecified