=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114111358
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REBECCA MAE VANAMBURG ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2007
-----------------------------------------------------
Last Update Date | 08/30/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5000 FORBES AVE CARNEGIE MELLON UNIVERSITY ATHLETICS DEPARTMENT
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15213-3815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-268-8972
-----------------------------------------------------
Fax | 412-268-4078
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5000 FORBES AVE CARNEGIE MELLON UNIVERSITY ATHLETICS DEPARTMENT
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15213-3815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-268-8972
-----------------------------------------------------
Fax | 412-268-4078
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | RT003070
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------