Provider Demographics
NPI:1366463515
Name:MEDINA, MARIA AILEENMICHELLE P (MD)
Entity Type:Individual
Prefix:
First Name:MARIA AILEENMICHELLE
Middle Name:P
Last Name:MEDINA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:P
Other - Last Name:MEDINA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:12000 MCCRACKEN RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:GARFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44125-2964
Mailing Address - Country:US
Mailing Address - Phone:216-584-7840
Mailing Address - Fax:216-584-7860
Practice Address - Street 1:12000 MCCRACKEN RD
Practice Address - Street 2:SUITE 206
Practice Address - City:GARFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44125-2964
Practice Address - Country:US
Practice Address - Phone:216-584-7840
Practice Address - Fax:216-584-7860
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH74782208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2741322Medicaid
OH400779OtherWELLCARE
OH2741322Medicaid
OH7371171Medicare PIN