Provider Demographics
NPI:1144219569
Name:HYSONG, REBECCA SUZANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:SUZANNE
Last Name:HYSONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2699
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2699
Mailing Address - Country:US
Mailing Address - Phone:850-475-4686
Mailing Address - Fax:850-475-4619
Practice Address - Street 1:619 N COVE BLVD
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-3642
Practice Address - Country:US
Practice Address - Phone:850-913-6960
Practice Address - Fax:850-913-6961
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18499208600000X
FLME85213208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL83220177Medicaid
MS0697784Medicaid
FL83220177Medicaid
MS0697784Medicaid
FLH75434Medicare UPIN