Healthcare Provider Details

I. General information

NPI: 1104268168
Provider Name (Legal Business Name): CARLINE MEKEM MBEUMO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2013
Last Update Date: 11/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3412 OFFICE PARK DRIVE
MARION IL
62959
US

IV. Provider business mailing address

3412 OFFICE PARK DRIVE
MARION IL
62959
US

V. Phone/Fax

Practice location:
  • Phone: 618-993-0404
  • Fax: 618-993-1717
Mailing address:
  • Phone: 618-993-0404
  • Fax: 618-993-1717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301103909
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036140445
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: