Provider Demographics
NPI:1093775736
Name:MATTISON, REBECCA SUZANNE (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:SUZANNE
Last Name:MATTISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:SUZANNE
Other - Last Name:KLOPCIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:7701 YORK AVE S
Mailing Address - Street 2:SUITE 180
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5845
Mailing Address - Country:US
Mailing Address - Phone:952-927-7810
Mailing Address - Fax:952-927-6309
Practice Address - Street 1:7701 YORK AVE S
Practice Address - Street 2:SUITE 180
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-5845
Practice Address - Country:US
Practice Address - Phone:952-927-7810
Practice Address - Fax:952-927-6309
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN41654174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3300159OtherSELECT CARE
MN3300003OtherMEDICA PRIMARY
MN142689C626OtherUCARE
MNHP33644OtherHEALTH PARTNERS
MN960541028184OtherPREFERRED ONE
MN1362715OtherAMERICA'S PPO
MN279224900Medicaid
MN3300159OtherMEDICA CHOICE
MN256L5MAOtherBLUE CROSS BLUE SHIELD
MN410999025OtherTRICARE
MN1362715OtherAMERICA'S PPO
G97390Medicare UPIN
MN3300159OtherMEDICA CHOICE