Provider Demographics
NPI:1043722556
Name:MERRITT, FREDERICK
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:
Last Name:MERRITT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 LOCUST ST UNIT 803
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-1810
Mailing Address - Country:US
Mailing Address - Phone:314-393-3335
Mailing Address - Fax:
Practice Address - Street 1:315 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-5813
Practice Address - Country:US
Practice Address - Phone:314-393-3335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-25
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)