Basic Information
| Provider Information | |||||||||
| NPI: | 1548571490 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDEL | ||||||||
| FirstName: | MARIETTA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 BELLEFONTAINE AVE | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458042800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199984575 | ||||||||
| FaxNumber: | 4199984586 | ||||||||
| Practice Location | |||||||||
| Address1: | 1005 BELLEFONTAINE AVE STE 350 | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458042885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199988200 | ||||||||
| FaxNumber: | 4199988203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2010 | ||||||||
| LastUpdateDate: | 09/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 35094582 | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.