Provider Demographics
NPI:1184311342
Name:MELLOY CONCIERGE AND AESTHETICS MEDICAL GROUP
Entity type:Organization
Organization Name:MELLOY CONCIERGE AND AESTHETICS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MELLOY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-239-4902
Mailing Address - Street 1:200 S 20TH ST STE C
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-1100
Mailing Address - Country:US
Mailing Address - Phone:479-278-7010
Mailing Address - Fax:479-974-2009
Practice Address - Street 1:200 S 20TH ST STE C
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-1100
Practice Address - Country:US
Practice Address - Phone:479-278-7010
Practice Address - Fax:479-974-2009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-19
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty