This case study explores the degree to which mathematical knowledge for teaching can be developed by prospective teachers in a multi-site teacher education context. The majority of the article focuses on a description of the target middle level mathematics endorsement program, including distance-based instructional norms, community building efforts, and tasks and activities intended to support the generation of mathematical knowledge for teaching. All preservice teachers enrolled in the program were invited to participate in the study. Means on Likert-scale survey items were calculated at three points in time over one year to determine changes. Open-ended survey items and focus group interviews were analyzed qualitatively to supplement the quantitative findings. These data support the result that middle level preservice teachers' mathematical knowledge for teaching can be positively impacted by a middle level mathematics teacher education program. Two broader implications are provided: 1) teacher education experiences can have positive impact on prospective teachers' development, and 2) this development is possible in a multi-site teacher education setting. Possible implications on international teacher education efforts are provided.