Provider Demographics
NPI:1518298389
Name:NICK MELLIS MD PA
Entity Type:Organization
Organization Name:NICK MELLIS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICK
Authorized Official - Middle Name:
Authorized Official - Last Name:MELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-560-5652
Mailing Address - Street 1:2352 YORK RD
Mailing Address - Street 2:
Mailing Address - City:TIMONIUM
Mailing Address - State:MD
Mailing Address - Zip Code:21093-2236
Mailing Address - Country:US
Mailing Address - Phone:410-560-5652
Mailing Address - Fax:
Practice Address - Street 1:2352 YORK RD
Practice Address - Street 2:
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-2236
Practice Address - Country:US
Practice Address - Phone:410-560-5652
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NICHOLAS MELLIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-19
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0047762207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG20385Medicare UPIN
MD142RMedicare PIN
MD179188Medicare PIN