1578546529 NPI number — VICENTE M MEDALLE MD

Table of content: VICENTE M MEDALLE MD (NPI 1578546529)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578546529 NPI number — VICENTE M MEDALLE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEDALLE
Provider First Name:
VICENTE
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578546529
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1460 N CENTER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48509-1429
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-715-4620
Provider Business Mailing Address Fax Number:
810-715-4602

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1460 N CENTER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48509-1429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-715-4620
Provider Business Practice Location Address Fax Number:
810-715-4602
Provider Enumeration Date:
11/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  4301033720 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207PE0004X , with the licence number: 4301033720 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: VM033720 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00213537 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3332980 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3332962 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3332971 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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