Provider Demographics
NPI:1053955039
Name:MINEOLA MEDICAL CENTER PLLC
Entity type:Organization
Organization Name:MINEOLA MEDICAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ADEREMI
Authorized Official - Middle Name:
Authorized Official - Last Name:ADEWUYI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-406-7240
Mailing Address - Street 1:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-0037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:415 W KILPATRICK ST
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:TX
Practice Address - Zip Code:75773-2032
Practice Address - Country:US
Practice Address - Phone:903-569-2006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-01
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty