Provider Demographics
NPI:1053861369
Name:MACHUCA MEDICAL LLC
Entity Type:Organization
Organization Name:MACHUCA MEDICAL LLC
Other - Org Name:MACHUCA MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD/ SOLO PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MACHUCA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-795-1101
Mailing Address - Street 1:7371 BRANDT PIKE
Mailing Address - Street 2:SUITE D
Mailing Address - City:HUBER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:45424
Mailing Address - Country:US
Mailing Address - Phone:937-795-1101
Mailing Address - Fax:937-795-1120
Practice Address - Street 1:7371 BRANDT PIKE STE D
Practice Address - Street 2:
Practice Address - City:HUBER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:45424-3276
Practice Address - Country:US
Practice Address - Phone:937-795-1101
Practice Address - Fax:937-795-1120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-11
Last Update Date:2024-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH92123207Q00000X
261QP2300X
OH35.092123207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2893301Medicaid
1669694246OtherINDIVIDUAL NPI
1053861369OtherGROUP NPI
MA4253051OtherLEGACY
H598960OtherPTAN