1861453359 NPI number — BRADLEY W MERRILLS MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861453359 NPI number — BRADLEY W MERRILLS MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

MERRILLS

Provider First Name:

BRADLEY

Provider Middle Name:

W

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

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:

1861453359

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

04/09/2021

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

501 LAPEER AVE

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

SAGINAW

Provider Business Mailing Address State Name:

MI

Provider Business Mailing Address Postal Code:

48607-1208

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

989-759-6400

Provider Business Mailing Address Fax Number:

989-759-6423

Provider First Line Business Practice Location Address:

3175 W PROFESSIONAL DRIVE

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

BAY CITY

Provider Business Practice Location Address State Name:

MI

Provider Business Practice Location Address Postal Code:

48706-2823

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

989-667-3777

Provider Business Practice Location Address Fax Number:

989-667-9991

Provider Enumeration Date:

04/01/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207V00000X , with the licence number:  4301061522 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 073 . This is a "COMMUNITY CHOICE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 1017360 . This is a "MCLAREN HEALTH PLAN PROFE" identifier . This identifiers is of the category "OTHER".
• Identifier: 4762091 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
• Identifier: 0998824 . This is a "BAY COUNTY HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
• Identifier: 150962 . This is a "GREAT LAKES HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
• Identifier: 0998824 . This is a "HEALTHPLUS" identifier . This identifiers is of the category "OTHER".
• Identifier: 1017362 . This is a "MCLAREN HEALTHPLAN MONITO" identifier . This identifiers is of the category "OTHER".
• Identifier: 4762073 . This is a "MOLINA HEALTH CARE PROFES" identifier . This identifiers is of the category "OTHER".
• Identifier: 5932486 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
• Identifier: 700G361110 . This is a "BLUE CROSS" identifier . This identifiers is of the category "OTHER".
• Identifier: 381908328 . This is a "HCAP" identifier . This identifiers is of the category "OTHER".
• Identifier: 4762073 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
• Identifier: 4762091 . This is a "MOLINA HEALTH CARE MONITO" identifier . This identifiers is of the category "OTHER".