Provider Demographics
NPI:1609079409
Name:MELVIN, REBECCA ELLEN (DO)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:ELLEN
Last Name:MELVIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 KISKER RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63304-8788
Mailing Address - Country:US
Mailing Address - Phone:636-498-5970
Mailing Address - Fax:636-498-5975
Practice Address - Street 1:1475 KISKER RD STE 200
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63304
Practice Address - Country:US
Practice Address - Phone:636-498-5970
Practice Address - Fax:636-498-5975
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-049-138207R00000X, 208000000X
TXP7810208000000X
MO2017007800208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL809840OtherMEDICARE GROUP NUMBER
IL809840011Medicare PIN