Healthcare Provider Details

I. General information

NPI: 1073508982
Provider Name (Legal Business Name): MELISSA K MCRAE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 02/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 MEADOW DR SUITE C
MOUNT GILEAD OH
43338-1063
US

IV. Provider business mailing address

7326 STATE ROUTE 19 UNIT 5014
MOUNT GILEAD OH
43338-9354
US

V. Phone/Fax

Practice location:
  • Phone: 419-946-1085
  • Fax: 419-946-1209
Mailing address:
  • Phone: 419-946-1527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34007177B
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: