Basic Information
Provider Information | |||||||||
NPI: | 1659330025 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FERNANDES | ||||||||
FirstName: | MILAGRES | ||||||||
MiddleName: | MARTIN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FERNANDES | ||||||||
OtherFirstName: | M | ||||||||
OtherMiddleName: | MARTIN | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 24701 EUCLID AVE | ||||||||
Address2: | THIRD FLOOR BILLING SERVICES | ||||||||
City: | EUCLID | ||||||||
State: | OH | ||||||||
PostalCode: | 441171714 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4403585555 | ||||||||
FaxNumber: | 4402585556 | ||||||||
Practice Location | |||||||||
Address1: | 7500 AUBURN RD # 2300 | ||||||||
Address2: |   | ||||||||
City: | CONCORD TWP | ||||||||
State: | OH | ||||||||
PostalCode: | 440779176 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4403585555 | ||||||||
FaxNumber: | 4403585556 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/22/2006 | ||||||||
LastUpdateDate: | 12/18/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35-043299 | OH | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 264168 | 01 | OH | FEDERAL BLACK LUNG | OTHER | 0403790 | 05 | OH |   | MEDICAID |