Basic Information
| Provider Information | |||||||||
| NPI: | 1467747659 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDINA CARBONELL | ||||||||
| FirstName: | FERNANDO | ||||||||
| MiddleName: | RAFAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1465 S GRAND BLVD, DEPT OF PEDIATRICS | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631041003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142684010 | ||||||||
| FaxNumber: | 3142682775 | ||||||||
| Practice Location | |||||||||
| Address1: | 1465 S GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631041003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142684010 | ||||||||
| FaxNumber: | 3142682775 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2011 | ||||||||
| LastUpdateDate: | 01/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0206X | 29938 | NE | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology | 2080P0206X | 2020001532 | MO | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
No ID Information.