Provider Demographics
NPI:1366526378
Name:MARIDEL HERNANDEZ INTERNAL MEDICINE PC
Entity type:Organization
Organization Name:MARIDEL HERNANDEZ INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIDEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:313-640-8400
Mailing Address - Street 1:131 KERCHEVAL AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:GROSSE POINTE FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-3629
Mailing Address - Country:US
Mailing Address - Phone:313-640-8400
Mailing Address - Fax:313-640-9232
Practice Address - Street 1:131 KERCHEVAL AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:GROSSE POINTE FARMS
Practice Address - State:MI
Practice Address - Zip Code:48236-3629
Practice Address - Country:US
Practice Address - Phone:313-640-8400
Practice Address - Fax:313-640-9232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012021207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E02258OtherBCBS PIN
MI1158213464OtherBLUE CROSS BLUE SHIELD
MI4869383-11Medicaid
MI1158213464OtherBLUE CROSS BLUE SHIELD
MIG60866Medicare UPIN
MI0E02258OtherBCBS PIN