Provider Demographics
NPI:1043434947
Name:ELLEN T MELVIN MD PA
Entity type:Organization
Organization Name:ELLEN T MELVIN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:THERESE
Authorized Official - Last Name:MELVIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-569-6869
Mailing Address - Street 1:3745 11TH CIR STE 103
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-4838
Mailing Address - Country:US
Mailing Address - Phone:772-569-6869
Mailing Address - Fax:772-569-8214
Practice Address - Street 1:3745 11TH CIR STE 103
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960
Practice Address - Country:US
Practice Address - Phone:772-569-6869
Practice Address - Fax:772-569-8214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME41899207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL440003585OtherRAILROAD MEDICARE PTAN
FL440003585OtherRAILROAD MEDICARE PTAN