Provider Demographics
NPI:1003218223
Name:MEDICAL WELLNESS GROUP LLC
Entity type:Organization
Organization Name:MEDICAL WELLNESS GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:A
Authorized Official - Last Name:SALHAB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-389-5545
Mailing Address - Street 1:6222 SOARING AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33617-1391
Mailing Address - Country:US
Mailing Address - Phone:813-765-1930
Mailing Address - Fax:
Practice Address - Street 1:1359 NE 35TH AVENUE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232
Practice Address - Country:US
Practice Address - Phone:503-389-5545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-18
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME119290207Q00000X
ORMD167486207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR177434OtherMEDICARE ID
OR1811200165OtherINDIVIDUAL SOLE PROVIDER NPI