Provider Demographics
NPI:1386604403
Name:MOUNT, MICHAEL T (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:MOUNT
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 250450
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36125-0450
Mailing Address - Country:US
Mailing Address - Phone:334-613-9000
Mailing Address - Fax:334-286-6311
Practice Address - Street 1:2119 E SOUTH BLVD
Practice Address - Street 2:#200
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-2495
Practice Address - Country:US
Practice Address - Phone:334-613-9000
Practice Address - Fax:334-286-6311
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA320363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
970027632OtherRAILROAD MEDICARE
AL51512941MOUOtherBCBS
AL051552391Medicaid
051552391Medicare ID - Type Unspecified
AL51512941MOUOtherBCBS