Basic Information
| Provider Information | |||||||||
| NPI: | 1184895849 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARIO DE MEIRELES MD MHSA PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9260 FELLOWS CREEK DR | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481706354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344620340 | ||||||||
| FaxNumber: | 7344620344 | ||||||||
| Practice Location | |||||||||
| Address1: | 9260 FELLOWS CREEK DR | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481706354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344620340 | ||||||||
| FaxNumber: | 7344620344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2008 | ||||||||
| LastUpdateDate: | 10/27/2020 | ||||||||
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| AuthorizedOfficialLastName: | DE MEIRELES | ||||||||
| AuthorizedOfficialFirstName: | MARIO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2483027686 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301061758 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4301061758 | 01 | MI | STATE LICENSE | OTHER |