Provider Demographics
NPI:1598009227
Name:AIEA MEDICAL GROUP,LLC
Entity Type:Organization
Organization Name:AIEA MEDICAL GROUP,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:DIMITRION
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-488-7770
Mailing Address - Street 1:98-1079 MOANALUA RD
Mailing Address - Street 2:SUITE 420
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-4713
Mailing Address - Country:US
Mailing Address - Phone:808-488-7770
Mailing Address - Fax:808-487-0104
Practice Address - Street 1:98-1079 MOANALUA RD
Practice Address - Street 2:SUITE 420
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-4713
Practice Address - Country:US
Practice Address - Phone:808-488-7770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-19
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI3107207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI03759701Medicaid
HIC98411Medicare UPIN
HIHBDFGRMedicare PIN