Provider Demographics
NPI:1275552531
Name:MERRELL, MARK R (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:MERRELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6703 W RIO GRANDE AVE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-2623
Mailing Address - Country:US
Mailing Address - Phone:509-460-5588
Mailing Address - Fax:509-783-5438
Practice Address - Street 1:6703 W RIO GRANDE AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-2623
Practice Address - Country:US
Practice Address - Phone:509-460-5588
Practice Address - Fax:509-783-5438
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00033754207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA990005359OtherRR MEDICARE
WA8192569Medicaid
WA116835OtherLABOR & INDUSTRIES
WA8192569Medicaid
WA116835OtherLABOR & INDUSTRIES
116835OtherLABOR & INDUSTRIES
AB01871Medicare PIN