=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578377628
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | M MEDICAL MI PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2025
-----------------------------------------------------
Last Update Date | 02/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5201 CONNER ST
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48213-3405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-571-5555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4806 U ST NW
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20007-1546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ENROLLMENT MANAGER
-----------------------------------------------------
Name | ALICIA ISABEL MENDEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-881-2313
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------