Provider Demographics
NPI:1366605180
Name:FERNANDEZ BRANDT, MELINA (MD)
Entity type:Individual
Prefix:
First Name:MELINA
Middle Name:
Last Name:FERNANDEZ BRANDT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 CREASE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-3902
Mailing Address - Country:US
Mailing Address - Phone:646-312-9036
Mailing Address - Fax:
Practice Address - Street 1:255 W LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-1763
Practice Address - Country:US
Practice Address - Phone:484-565-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-11397207R00000X
NJ25MA11066600207R00000X
PAMD434479208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1022607630003Medicaid
PA2089028OtherHIGHMARK BLUE SHIELD
PA3713526000OtherINDEPENDENCE BLUE CROSS
PA1022607630001Medicaid
PAP000805685OtherRR MEDICARE
PA1022607630002Medicaid
PA30067974OtherKEYSTONE MERCY HEALTH PLAN
PA1022607630003Medicaid