Individual
VICENTE M MEDALLE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1460 N CENTER RD, BURTON, MI 48509-1429
(810) 715-4620
(810) 715-4602
Mailing address
1460 N CENTER RD, BURTON, MI 48509-1429
(810) 715-4620
(810) 715-4602
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
4301033720
MI
207PE0004X
Emergency Medical Services (Emergency Medicine) Physician
Primary
4301033720
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
3332962
—
MI
05
—
3332971
—
MI
05
—
3332980
—
MI
01
—
P00213537
RAILROAD MEDICARE
—
01
—
VM033720
BLUE CROSS BLUE SHIELD
—
Enumeration date
11/23/2005
Last updated
09/30/2011
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