Provider Demographics
NPI:1083166599
Name:MELBY MEDICAL LLC
Entity Type:Organization
Organization Name:MELBY MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:A
Authorized Official - Last Name:MELBY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:757-377-7137
Mailing Address - Street 1:1148 WESSINGTON MANOR LN
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-7806
Mailing Address - Country:US
Mailing Address - Phone:757-377-7137
Mailing Address - Fax:
Practice Address - Street 1:1148 WESSINGTON MANOR LN
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-7806
Practice Address - Country:US
Practice Address - Phone:757-377-7137
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-01
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDO36425207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty