Provider Demographics
NPI:1528145935
Name:DEMELLO MEDICAL CLINIC
Entity type:Organization
Organization Name:DEMELLO MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:DEMELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:586-228-0600
Mailing Address - Street 1:39379 GARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CILNTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038
Mailing Address - Country:US
Mailing Address - Phone:586-228-0600
Mailing Address - Fax:586-228-1839
Practice Address - Street 1:39379 GARFIELD RD
Practice Address - Street 2:
Practice Address - City:CILNTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038
Practice Address - Country:US
Practice Address - Phone:586-228-0600
Practice Address - Fax:586-228-1839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDD007358207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4939290Medicaid
E25675Medicare UPIN
MIOP28970Medicare ID - Type Unspecified