Provider Demographics
NPI:1336359140
Name:MITTLEMAN, RACHAL MARIE (MD)
Entity type:Individual
Prefix:
First Name:RACHAL
Middle Name:MARIE
Last Name:MITTLEMAN
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 1:3235 N WELLNESS DR
Mailing Address - Street 2:BLDG A SUITE 120A
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-7264
Mailing Address - Country:US
Mailing Address - Phone:616-399-0902
Mailing Address - Fax:
Practice Address - Street 1:3235 N WELLNESS DR
Practice Address - Street 2:BLDG A SUITE 120A
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-7264
Practice Address - Country:US
Practice Address - Phone:616-399-0902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000041709207R00000X, 208000000X
MI4301093140207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3000597Medicaid
TN3000597Medicare PIN