1154314342 NPI number — MARELYN MEDINA MD

Table of content: MARELYN MEDINA MD (NPI 1154314342)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154314342 NPI number — MARELYN MEDINA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEDINA
Provider First Name:
MARELYN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1154314342
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/25/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
412 E DOVE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCALLEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78504-2240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-686-7243
Provider Business Mailing Address Fax Number:
956-668-7123

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
412 E DOVE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCALLEN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78504-2240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-686-7243
Provider Business Practice Location Address Fax Number:
956-668-7123
Provider Enumeration Date:
08/24/2005

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: 208800000X , with the licence number:  J9759 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 340017711 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3196639 . This is a "BCBS BLUE LINK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 82010Y . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 16886101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036004201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1258210001 . This is a "PALMETTO DME" identifier . This identifiers is of the category "OTHER".




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