MEDICARE: MINA MICHAEL 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

General Provider Information

NPI Number	:	1912789835
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINA MICHAEL LLC

Provider Business Mailing Address
First Line	:	PO BOX 242198
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72223-0021
Country	:	US
Telephone Number	:	346-907-4805
Fax Number	:

Provider Business Practice Location Address
First Line	:	1355 DAVE WARD DR STE 102
Second Line	:
City	:	CONWAY
State	:	AR
Zip	:	72034-7082
Country	:	US
Telephone Number	:	346-907-4805
Fax Number	:

Authorized Official
Title or Position	:	OWNER OF ENTITY
Name	:	MINA MICHAEL KAMEL MICHAEL
Credential	:	MD
Telephone Number	:	346-907-4805

Provider Enumeration Date	:	10/16/2023
Last Update Date	:	05/06/2024

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Directions to “MINA MICHAEL LLC ” Practice Location

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