Provider Demographics
NPI:1659312932
Name:MEDINA, LOIDA S (MD)
Entity Type:Individual
Prefix:MRS
First Name:LOIDA
Middle Name:S
Last Name:MEDINA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 PIPESTONE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-2304
Mailing Address - Country:US
Mailing Address - Phone:269-925-6600
Mailing Address - Fax:269-925-9528
Practice Address - Street 1:1850 PIPESTONE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-2304
Practice Address - Country:US
Practice Address - Phone:269-925-6600
Practice Address - Fax:269-925-9528
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301037695174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0101100342OtherBCBS PIN NUMBER
MI0N57150Medicare PIN