Provider Demographics
NPI:1912213604
Name:R M BEREDO M D P L L C
Entity Type:Organization
Organization Name:R M BEREDO M D P L L C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROLANDO
Authorized Official - Middle Name:M
Authorized Official - Last Name:BEREDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-788-6336
Mailing Address - Street 1:426 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1235
Mailing Address - Country:US
Mailing Address - Phone:517-788-6336
Mailing Address - Fax:517-788-9035
Practice Address - Street 1:426 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1235
Practice Address - Country:US
Practice Address - Phone:517-788-6336
Practice Address - Fax:517-788-9035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-19
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301060312174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M90970Medicare PIN