Provider Demographics
NPI:1548671084
Name:BLICKENDORF, REBEKAH ANN (MD)
Entity type:Individual
Prefix:DR
First Name:REBEKAH
Middle Name:ANN
Last Name:BLICKENDORF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:REBEKAH
Other - Middle Name:ANN
Other - Last Name:ZAISER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1701 N SENATE BLVD RM AG012
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-1239
Mailing Address - Country:US
Mailing Address - Phone:724-766-0017
Mailing Address - Fax:
Practice Address - Street 1:1701 N SENATE BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1239
Practice Address - Country:US
Practice Address - Phone:317-962-3886
Practice Address - Fax:317-963-5492
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-19
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01075265A207P00000X
IN11017542A390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201233400Medicaid
INP01719333Medicare PIN
IN201233400Medicaid