Basic Information
| Provider Information | |||||||||
| NPI: | 1649251539 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEDERO-ENG | ||||||||
| FirstName: | MIRIAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 PERIMETER PARK DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | MORRISVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275608442 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3801 COMPUTER DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276096506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197825273 | ||||||||
| FaxNumber: | 9197818853 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2005 | ||||||||
| LastUpdateDate: | 05/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 2007-00183 | NC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 5908220 | 05 | NC | MEDICAID |