MEDICARE: MRS. REBECCA LYNN GICEWICZ PA C

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	363A00000X	Physician Assistant	PA 3519	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	04095	OTHER	FL	BCBS OF FL

General Provider Information

NPI Number	:	1164453965
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. REBECCA LYNN GICEWICZ PA C

Provider Business Mailing Address
First Line	:	402 W 19TH ST
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-4602
Country	:	US
Telephone Number	:	850-763-6179
Fax Number	:	850-763-0412

Provider Business Practice Location Address
First Line	:	402 W 19TH ST
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-4602
Country	:	US
Telephone Number	:	850-763-6179
Fax Number	:	850-763-0412

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

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	07/08/2007

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