Provider Demographics
NPI:1518128073
Name:MIHALIK, SCOTT A (PA-C)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
Last Name:MIHALIK
Suffix:
Gender:M
Credentials:PA-C
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 11091
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46634-0091
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3950 HOLLYWOOD RD STE 110
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9151
Practice Address - Country:US
Practice Address - Phone:269-985-1000
Practice Address - Fax:269-983-3181
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005294363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601005294OtherSTATE LICENSE