Provider Demographics
NPI:1104268168
Name:MBEUMO, CARLINE MEKEM (MD)
Entity type:Individual
Prefix:
First Name:CARLINE
Middle Name:MEKEM
Last Name:MBEUMO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3412 OFFICE PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959
Mailing Address - Country:US
Mailing Address - Phone:618-993-0404
Mailing Address - Fax:618-993-1717
Practice Address - Street 1:3412 OFFICE PARK DRIVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959
Practice Address - Country:US
Practice Address - Phone:618-993-0404
Practice Address - Fax:618-993-1717
Is Sole Proprietor?:No
Enumeration Date:2013-07-18
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301103909208000000X
IL036140445208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036140445Medicaid