MEDICARE: MACHUCA MEDICAL LLC

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	261QP2300X	Primary Care Clinic/Center
2	207Q00000X	Family Medicine Physician	92123	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1053861369	OTHER		GROUP NPI
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	H59861	OTHER	OH	OTHER
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	1669694246	OTHER		INDIVIDUAL NPI
6	H598960	OTHER		PTAN
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	MA4253051	OTHER		LEGACY

General Provider Information

NPI Number	:	1053861369
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MACHUCA MEDICAL LLC

Provider Business Mailing Address
First Line	:	8648 OLD TROY PIKE STE A
Second Line	:
City	:	HUBER HEIGHTS
State	:	OH
Zip	:	45424-1057
Country	:	US
Telephone Number	:	937-795-1101
Fax Number	:	937-795-1120

Provider Business Practice Location Address
First Line	:	8648 OLD TROY PIKE STE A
Second Line	:
City	:	HUBER HEIGHTS
State	:	OH
Zip	:	45424-1057
Country	:	US
Telephone Number	:	937-795-1101
Fax Number	:	937-795-1120

Authorized Official
Title or Position	:	OWNER/ SOLO PHYSICIAN
Name	:	DR. JENNIFER LYNN MACHUCA
Credential	:	MD
Telephone Number	:	937-795-1101

Provider Enumeration Date	:	10/11/2016
Last Update Date	:	12/31/2025

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Directions to “MACHUCA MEDICAL LLC ” Practice Location

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