Provider Demographics
NPI:1578546529
Name:MEDALLE, VICENTE M (MD)
Entity Type:Individual
Prefix:
First Name:VICENTE
Middle Name:M
Last Name:MEDALLE
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 1:1460 N CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48509-1429
Mailing Address - Country:US
Mailing Address - Phone:810-715-4620
Mailing Address - Fax:810-715-4602
Practice Address - Street 1:1460 N CENTER RD
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-1429
Practice Address - Country:US
Practice Address - Phone:810-715-4620
Practice Address - Fax:810-715-4602
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301033720207P00000X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VM033720OtherBLUE CROSS BLUE SHIELD
P00213537OtherRAILROAD MEDICARE
MI3332980Medicaid
MI3332962Medicaid
MI3332971Medicaid
MI3332980Medicaid
MIB56088049Medicare Oscar/Certification