Provider Demographics
NPI:1194710566
Name:MELTZER, MIRIAM REBECCA
Entity type:Individual
Prefix:MRS
First Name:MIRIAM
Middle Name:REBECCA
Last Name:MELTZER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3007 W KENT DR
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-1920
Mailing Address - Country:US
Mailing Address - Phone:618-457-7788
Mailing Address - Fax:618-457-7788
Practice Address - Street 1:3007 W KENT DR
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1920
Practice Address - Country:US
Practice Address - Phone:618-457-7788
Practice Address - Fax:618-457-7788
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2008-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
O67495Medicare UPIN
IL0674950001Medicare NSC