Provider Demographics
NPI:1912244310
Name:ELEANOR MEDINA MD PC
Entity Type:Organization
Organization Name:ELEANOR MEDINA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ELEANOR
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-258-5839
Mailing Address - Street 1:60 BALFOUR DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-2100
Mailing Address - Country:US
Mailing Address - Phone:248-258-5839
Mailing Address - Fax:
Practice Address - Street 1:60 BALFOUR DR
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-2100
Practice Address - Country:US
Practice Address - Phone:248-258-5839
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-07
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26063045822084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
B48319Medicare UPIN