Provider Demographics
NPI:1144246489
Name:MERRILL, STEPHEN L (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:L
Last Name:MERRILL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3524 E MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-1626
Mailing Address - Country:US
Mailing Address - Phone:608-756-7100
Mailing Address - Fax:608-756-4700
Practice Address - Street 1:3524 E MILWAUKEE ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-1626
Practice Address - Country:US
Practice Address - Phone:608-756-7100
Practice Address - Fax:608-756-4700
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036049241207P00000X, 207Q00000X
WI51728207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
215652OtherMEDICARE GROUP #
WIMERRISTEOtherMERCYCARE INSURANCE
IL036049241Medicaid
553180OtherMEDICARE #
IL553180OtherMEDICARE GROUP
WIP00612688CD3624OtherRR MEDICARE
834340OtherMEDICARE GROUP #
IL553180OtherMEDICARE GROUP
IL036049241Medicaid
WIP00612688CD3624OtherRR MEDICARE
215652OtherMEDICARE GROUP #
WI541760714Medicare PIN
553180OtherMEDICARE #