Provider Demographics
NPI:1326051947
Name:MERRYMAN, JOHN E (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:MERRYMAN
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 1:125 PORTMAN AVE
Mailing Address - Street 2:
Mailing Address - City:STANFORD
Mailing Address - State:KY
Mailing Address - Zip Code:40484-1229
Mailing Address - Country:US
Mailing Address - Phone:606-365-3378
Mailing Address - Fax:606-365-3380
Practice Address - Street 1:130 DANIEL DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-2527
Practice Address - Country:US
Practice Address - Phone:859-236-2222
Practice Address - Fax:859-236-2227
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34364208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64343643Medicaid
KYG73982Medicare UPIN
KY64343643Medicaid