MEDICARE: MATTHEW MITZMAN

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	2255A2300X	Athletic Trainer	A0000689	MD

General Provider Information

NPI Number	:	1629525357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW MITZMAN

Provider Business Mailing Address
First Line	:	1418 CAMBIUM CT
Second Line	:
City	:	HANOVER
State	:	MD
Zip	:	21076-1680
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8501 BAYSIDE RD
Second Line	:
City	:	CHESAPEAKE BEACH
State	:	MD
Zip	:	20732-3350
Country	:	US
Telephone Number	:	443-964-5656
Fax Number	:

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

Provider Enumeration Date	:	09/11/2016
Last Update Date	:	09/11/2016

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