Provider Demographics
NPI:1588726921
Name:MEDINA, ELEANOR M (MD)
Entity type:Individual
Prefix:DR
First Name:ELEANOR
Middle Name:M
Last Name:MEDINA
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 1:60 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:248-258-5839
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:248-258-5839
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010431022084F0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN36890002Medicare ID - Type Unspecified