Provider Demographics
NPI:1710240676
Name:ROGELIA B. MEDIDAS M.D., INC.
Entity Type:Organization
Organization Name:ROGELIA B. MEDIDAS M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGELIA
Authorized Official - Middle Name:BULILAN
Authorized Official - Last Name:MEDIDAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:216-749-4733
Mailing Address - Street 1:7003 MEMPHIS AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:BROOKLYN
Mailing Address - State:OH
Mailing Address - Zip Code:44144-2216
Mailing Address - Country:US
Mailing Address - Phone:216-749-4733
Mailing Address - Fax:216-749-4734
Practice Address - Street 1:7003 MEMPHIS AVE
Practice Address - Street 2:SUITE A
Practice Address - City:BROOKLYN
Practice Address - State:OH
Practice Address - Zip Code:44144-2216
Practice Address - Country:US
Practice Address - Phone:216-749-4733
Practice Address - Fax:216-749-4734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-16
Last Update Date:2012-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.034992207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0216420Medicaid
OH0216420Medicaid