Provider Demographics
NPI:1396940573
Name:MIRAY MEDICAL CORP
Entity type:Organization
Organization Name:MIRAY MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RENOLT
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMAAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-586-8012
Mailing Address - Street 1:348 N PEARL ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1197
Mailing Address - Country:US
Mailing Address - Phone:508-586-8012
Mailing Address - Fax:508-583-2779
Practice Address - Street 1:348 N PEARL ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1197
Practice Address - Country:US
Practice Address - Phone:508-586-8012
Practice Address - Fax:508-583-2779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA71989207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9768033Medicaid
MA9768033Medicaid