MEDICARE: ANDRE MUELENAER JR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	0101-047216	VA
2	2080P0214X	Pediatric Pulmonology Physician	29353	NC
3	2080P0214X	Pediatric Pulmonology Physician	0101-047216	VA
4	208000000X	Pediatrics Physician	29353	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255303525
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDRE MUELENAER JR. MD

Provider Business Mailing Address
First Line	:	102 HIGHLAND AVE SE
Second Line	:	SUITE 203
City	:	ROANOKE
State	:	VA
Zip	:	24013-2256
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	102 HIGHLAND AVE SE
Second Line	:	SUITE 203
City	:	ROANOKE
State	:	VA
Zip	:	24013-2256
Country	:	US
Telephone Number	:	540-985-9835
Fax Number	:	540-985-4018

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2006
Last Update Date	:	04/30/2019

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