1467482323 NPI number — MR. ALBERT LOUIS MERIC III MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467482323 NPI number — MR. ALBERT LOUIS MERIC III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MERIC
Provider First Name:
ALBERT
Provider Middle Name:
LOUIS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
III
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MERIC
Provider Other First Name:
BERT
Provider Other Middle Name:
LOUIS
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1467482323
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16 WALNUT CRK
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92602-1046
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-375-8996
Provider Business Mailing Address Fax Number:
949-209-1980

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3931 LOUISIANA AVE S
Provider Second Line Business Practice Location Address:
SUITE EAST 500
Provider Business Practice Location Address City Name:
ST LOUIS PARK
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55426-4375
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-993-2079
Provider Business Practice Location Address Fax Number:
952-993-2701
Provider Enumeration Date:
07/04/2006

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: 207T00000X , with the licence number:  MD 018355 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207T00000X , with the licence number: 50069 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207T00000X , with the licence number: C53082 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207T00000X , with the licence number: 10495 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207T00000X , with the licence number: E-5123 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207T00000X , with the licence number: 38056 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 067463200 . This is a "MN MEDICAL ASSISTANCE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 3076786 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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