Healthcare Provider Details

I. General information

NPI: 1578546529
Provider Name (Legal Business Name): VICENTE M MEDALLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 09/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1460 N CENTER RD
BURTON MI
48509-1429
US

IV. Provider business mailing address

1460 N CENTER RD
BURTON MI
48509-1429
US

V. Phone/Fax

Practice location:
  • Phone: 810-715-4620
  • Fax: 810-715-4602
Mailing address:
  • Phone: 810-715-4620
  • Fax: 810-715-4602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301033720
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number4301033720
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: