Provider Demographics
NPI:1548545809
Name:ALAN MEDINA, MD PA
Entity type:Organization
Organization Name:ALAN MEDINA, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-856-6519
Mailing Address - Street 1:19 NEW WATER OAK DR
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-6958
Mailing Address - Country:US
Mailing Address - Phone:917-856-6519
Mailing Address - Fax:386-597-2948
Practice Address - Street 1:19 NEW WATER OAK DR
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-6958
Practice Address - Country:US
Practice Address - Phone:917-856-6519
Practice Address - Fax:386-597-2948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-19
Last Update Date:2021-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY170738261QM2500X
2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E87426Medicare UPIN
A100057330Medicare PIN