=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124026216
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY ANN MIKNEVICH MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2005
-----------------------------------------------------
Last Update Date | 01/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1350 LOCUST ST STE 409
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15219-4738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-232-7608
-----------------------------------------------------
Fax | 412-281-3536
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 598
-----------------------------------------------------
City | WEXFORD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15090-0598
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-622-4314
-----------------------------------------------------
Fax | 412-622-4882
-----------------------------------------------------
=====================================================
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 | MD025845E
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------