Provider Demographics
NPI:1164645214
Name:CLINTON F MERRILL MD PC
Entity Type:Organization
Organization Name:CLINTON F MERRILL MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:F
Authorized Official - Last Name:MERRILL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-742-7586
Mailing Address - Street 1:255 N 30TH ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072-5140
Mailing Address - Country:US
Mailing Address - Phone:307-742-7586
Mailing Address - Fax:
Practice Address - Street 1:255 N 30TH ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-5140
Practice Address - Country:US
Practice Address - Phone:307-742-7586
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3277A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1992707285OtherNPI
WY1992707285OtherNPI
WYC99974Medicare UPIN