Provider Demographics
NPI:1922040575
Name:MEDVED, MARINA
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:MEDVED
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 4TH ST
Mailing Address - Street 2:NORTH COUNTRY HEALTHCARE
Mailing Address - City:MALONE
Mailing Address - State:NY
Mailing Address - Zip Code:12953-1329
Mailing Address - Country:US
Mailing Address - Phone:518-481-6044
Mailing Address - Fax:
Practice Address - Street 1:24 4TH ST
Practice Address - Street 2:NORTH COUNTRY HEALTHCARE
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-1329
Practice Address - Country:US
Practice Address - Phone:518-481-6044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY219878207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5996909OtherGHI FAMILY HEALTH PLUS
NYP010219878OtherEXCELLUS BCBS
NY364144OtherMVP HEALTH PLAN
NY02409772Medicaid
NYP010219878OtherEXCELLUS BCBS
NYH52998Medicare UPIN
NYP00189181Medicare ID - Type UnspecifiedPA.METTO GBA-RR MEDICARE