Basic Information
| Provider Information | |||||||||
| NPI: | 1174528541 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITROVIC | ||||||||
| FirstName: | AILEEN | ||||||||
| MiddleName: | BERNAS | ||||||||
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| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BERNAS | ||||||||
| OtherFirstName: | AILEEN | ||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 500 UNIVERSITY DR | ||||||||
| Address2: | MC A410 | ||||||||
| City: | HERSHEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170332360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1800243145 | ||||||||
| FaxNumber: | 7175317269 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 HOPE DR | ||||||||
| Address2: | MC EC130 | ||||||||
| City: | HERSHEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170332036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175318070 | ||||||||
| FaxNumber: | 7175310138 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2005 | ||||||||
| LastUpdateDate: | 01/18/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT009143E | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 10115472 | 05 | PA | MEDICAID |