MEDICARE: MRS. LOIDA S MEDINA M.D.

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	174400000X	Specialist	4301037695	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0101100342	OTHER	MI	BCBS PIN NUMBER

General Provider Information

NPI Number	:	1659312932
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LOIDA S MEDINA M.D.

Provider Business Mailing Address
First Line	:	1850 PIPESTONE RD
Second Line	:	SUITE 101
City	:	BENTON HARBOR
State	:	MI
Zip	:	49022-2304
Country	:	US
Telephone Number	:	269-925-6600
Fax Number	:	269-925-9528

Provider Business Practice Location Address
First Line	:	1850 PIPESTONE RD
Second Line	:	SUITE 101
City	:	BENTON HARBOR
State	:	MI
Zip	:	49022-2304
Country	:	US
Telephone Number	:	269-925-6600
Fax Number	:	269-925-9528

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2006
Last Update Date	:	07/09/2007

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