Provider Demographics
NPI:1003802281
Name:VISCARRA, MERRIE (DO)
Entity Type:Individual
Prefix:
First Name:MERRIE
Middle Name:
Last Name:VISCARRA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 INDUSTRIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-2452
Mailing Address - Country:US
Mailing Address - Phone:414-858-4106
Mailing Address - Fax:414-423-4134
Practice Address - Street 1:1530 N RANDALL RD STE 210
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-7879
Practice Address - Country:US
Practice Address - Phone:224-760-7322
Practice Address - Fax:224-535-8252
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036113267208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036113267Medicaid
IL1633786OtherBCBS PROVIDER ID
ILP00255743OtherRAILROAD MEDICARE
ILP00255743OtherRAILROAD MEDICARE