Provider Demographics
NPI:1093704322
Name:BEREDO, ROLANDO MANALO (MD)
Entity Type:Individual
Prefix:
First Name:ROLANDO
Middle Name:MANALO
Last Name:BEREDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1414
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49204-1414
Mailing Address - Country:US
Mailing Address - Phone:517-788-6336
Mailing Address - Fax:517-788-9035
Practice Address - Street 1:426 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1235
Practice Address - Country:US
Practice Address - Phone:517-788-6336
Practice Address - Fax:517-788-9035
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRB060312207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI420017OtherPHP
MIC1796OtherMCARE
MI1103863092OtherBCBS OF MICHIGAN
MI4179560Medicaid
0M90970Medicare ID - Type Unspecified
MI1103863092OtherBCBS OF MICHIGAN