Provider Demographics
NPI:1194039321
Name:GREGORIO MEDALLE PA
Entity Type:Organization
Organization Name:GREGORIO MEDALLE PA
Other - Org Name:GREGORIO N. MEDALLE, M.D., P.A.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GREGORIO
Authorized Official - Middle Name:N
Authorized Official - Last Name:MEDALLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-773-3773
Mailing Address - Street 1:1052 DOWNING CIR
Mailing Address - Street 2:
Mailing Address - City:WAUCHULA
Mailing Address - State:FL
Mailing Address - Zip Code:33873-3358
Mailing Address - Country:US
Mailing Address - Phone:863-773-3773
Mailing Address - Fax:863-773-0358
Practice Address - Street 1:1052 DOWNING CIR
Practice Address - Street 2:
Practice Address - City:WAUCHULA
Practice Address - State:FL
Practice Address - Zip Code:33873-3358
Practice Address - Country:US
Practice Address - Phone:863-773-3773
Practice Address - Fax:863-773-0358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-29
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0044016208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty