=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023093812
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REBECCA LYNNE BACZUK MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2005
-----------------------------------------------------
Last Update Date | 02/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 N LAKEMONT AVE
-----------------------------------------------------
City | WINTER PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32792-3273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-303-1332
-----------------------------------------------------
Fax | 407-303-0347
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2388 BAYS EDGE AVE
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-991-4647
-----------------------------------------------------
Fax | 443-458-7224
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 0101236813
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | ME153039
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------