MEDICARE: MESA 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	207R00000X	Internal Medicine Physician	ME99661	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477967511
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MESA MEDICAL LLC

Provider Business Mailing Address
First Line	:	1870 FOREST HILL BLVD
Second Line	:	STE 101
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33406-6057
Country	:	US
Telephone Number	:	561-766-2373
Fax Number	:	561-766-2615

Provider Business Practice Location Address
First Line	:	1870 FOREST HILL BLVD
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33406-6057
Country	:	US
Telephone Number	:	561-766-2373
Fax Number	:	561-766-2615

Authorized Official
Title or Position	:	DOCTOR
Name	:	DR. ANGEL R MESA
Credential	:	M.D.
Telephone Number	:	561-766-2373

Provider Enumeration Date	:	06/17/2014
Last Update Date	:	06/17/2014

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Directions to “MESA MEDICAL LLC ” Practice Location

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