1720458599 NPI number — DR. RICHARD MARK MERRILL NURSE PRACTITIONER

Table of content: DR. RICHARD MARK MERRILL NURSE PRACTITIONER (NPI 1720458599)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720458599 NPI number — DR. RICHARD MARK MERRILL NURSE PRACTITIONER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MERRILL
Provider First Name:
RICHARD
Provider Middle Name:
MARK
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
NURSE PRACTITIONER
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MERRILL
Provider Other First Name:
RICHARD
Provider Other Middle Name:
MARK
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
CPNP - AC/PC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1720458599
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PSC 50 BOX 563
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APO
Provider Business Mailing Address State Name:
AE
Provider Business Mailing Address Postal Code:
09494-0006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
422 MDS/SGN
Provider Second Line Business Practice Location Address:
UNIT 4628
Provider Business Practice Location Address City Name:
APO
Provider Business Practice Location Address State Name:
AE
Provider Business Practice Location Address Postal Code:
09494-4628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-236-8125
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/05/2015

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: 363LP0222X , with the licence number:  9361765-4405 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0200X , with the licence number: 9361765-4405 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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