Provider Demographics
NPI:1073159208
Name:MEDPROFESSIONAL CONSULT LLC
Entity Type:Organization
Organization Name:MEDPROFESSIONAL CONSULT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAWADROUS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:414-793-5659
Mailing Address - Street 1:1411 RIVERSIDE OAKS DR
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-2425
Mailing Address - Country:US
Mailing Address - Phone:414-793-5659
Mailing Address - Fax:
Practice Address - Street 1:5242 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-5001
Practice Address - Country:US
Practice Address - Phone:972-772-8700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-22
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty