Provider Demographics
NPI:1417133372
Name:M & M MEDICAL CLINIC
Entity Type:Organization
Organization Name:M & M MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MULUKEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:FREW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-872-2777
Mailing Address - Street 1:PO BOX 441
Mailing Address - Street 2:
Mailing Address - City:SOUTH HILL
Mailing Address - State:VA
Mailing Address - Zip Code:23970-0441
Mailing Address - Country:US
Mailing Address - Phone:434-447-8580
Mailing Address - Fax:434-447-8538
Practice Address - Street 1:1911 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6509
Practice Address - Country:US
Practice Address - Phone:813-872-2777
Practice Address - Fax:813-872-2775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL35102OtherBLUE CROSS BLUE SHIELD
FL35102OtherBLUE CROSS BLUE SHIELD
H52586Medicare UPIN