MEDICARE: ELIZABETH ANN MOUNTCASTLE MD

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	207N00000X	Dermatology Physician	00009695	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	631066099	OTHER	AL	TAX#
2	510-82148	OTHER	AL	BLUE CROSS BLUE SHIELD
3	511-30221	OTHER	AL	BCBS
4	45-3970660	OTHER		FED TAX #
5	CM4358	OTHER	AL	RR MCR
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114037215
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH ANN MOUNTCASTLE MD

Provider Business Mailing Address
First Line	:	PO BOX 241627
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36124-1627
Country	:	US
Telephone Number	:	334-396-1555
Fax Number	:	334-396-9833

Provider Business Practice Location Address
First Line	:	286 MITYLENE PARK DR
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36117-3548
Country	:	US
Telephone Number	:	334-396-1555
Fax Number	:	334-396-9833

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	01/09/2013

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Directions to “ ELIZABETH ANN MOUNTCASTLE MD” Practice Location

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