MEDICARE: REBECCA LYNN MITTELSTADT P.A.

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	363AS0400X	Surgical Physician Assistant	PA405	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	51000413	OTHER	AL	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1841267226
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REBECCA LYNN MITTELSTADT P.A.

Provider Business Mailing Address
First Line	:	2709 LEGENDS PKWY
Second Line	:
City	:	PRATTVILLE
State	:	AL
Zip	:	36066-7755
Country	:	US
Telephone Number	:	334-310-1117
Fax Number	:

Provider Business Practice Location Address
First Line	:	2709 LEGENDS PKWY
Second Line	:
City	:	PRATTVILLE
State	:	AL
Zip	:	36066-7755
Country	:	US
Telephone Number	:	334-310-1117
Fax Number	:

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

Provider Enumeration Date	:	03/03/2006
Last Update Date	:	09/24/2020

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