MEDICARE: MD MEDCO 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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1245981331
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MD MEDCO LLC

Provider Business Mailing Address
First Line	:	118 BROADWAY ST STE 607
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78205-1983
Country	:	US
Telephone Number	:	210-374-4580
Fax Number	:

Provider Business Practice Location Address
First Line	:	118 BROADWAY ST STE 607
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78205-1983
Country	:	US
Telephone Number	:	210-374-4580
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TERRY CORLESS
Credential	:
Telephone Number	:	210-669-3730

Provider Enumeration Date	:	01/11/2022
Last Update Date	:	01/11/2022

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