Basic Information
Provider Information | |||||||||
NPI: | 1639297443 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MELICOR | ||||||||
FirstName: | REBECCA | ||||||||
MiddleName: | V | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5080 SPECTRUM DRIVE | ||||||||
Address2: | SUITE 1200 WEST TOWER | ||||||||
City: | ADDISON | ||||||||
State: | TX | ||||||||
PostalCode: | 750014648 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8002323550 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 627 E. MAPLE RD. | ||||||||
Address2: | SUITE 200 | ||||||||
City: | TROY | ||||||||
State: | MI | ||||||||
PostalCode: | 480832812 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6157784066 | ||||||||
FaxNumber: | 6157789114 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/27/2007 | ||||||||
LastUpdateDate: | 04/14/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083X0100X | 4301039155 | MI | Y |   | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine |
No ID Information.