1326023748 NPI number — AMY M MERRY PT

Table of content: AMY M MERRY PT (NPI 1326023748)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326023748 NPI number — AMY M MERRY PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MERRY
Provider First Name:
AMY
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326023748
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
625 ENTERPRISE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK BROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60523-8813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-575-6200
Provider Business Mailing Address Fax Number:
630-928-5080

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 WESTERVILLE PLZ
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTERVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43081-2882
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-791-8015
Provider Business Practice Location Address Fax Number:
614-794-3552
Provider Enumeration Date:
12/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT 003963 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2614488 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 311356625029 . This is a "CARESOURCE MCO" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000372031 . This is a "ANTHEM PROVIDER NUMBER" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 23-2804807 . This is a "REHAB PROVIDER NETWORK" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 31-1356625 . This is a "GREAT WEST PROVIDER NUMBE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 685840 . This is a "UHC" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 9400939 . This is a "PHCS NETWORK" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 11648861 . This is a "CAQH NUMBER" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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