Basic Information
| Provider Information | |||||||||
| NPI: | 1104268168 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MBEUMO | ||||||||
| FirstName: | CARLINE | ||||||||
| MiddleName: | MEKEM | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3412 OFFICE PARK DRIVE | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189930404 | ||||||||
| FaxNumber: | 6189931717 | ||||||||
| Practice Location | |||||||||
| Address1: | 3412 OFFICE PARK DRIVE | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189930404 | ||||||||
| FaxNumber: | 6189931717 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2013 | ||||||||
| LastUpdateDate: | 11/07/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4301103909 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 036140445 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 036140445 | 05 | IL | MEDICAID |