Provider Demographics
NPI:1407897051
Name:MERRELL, KEVIN TRACY (MD,PHD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:TRACY
Last Name:MERRELL
Suffix:
Gender:M
Credentials:MD,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1241 W MINERAL AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80120-5685
Mailing Address - Country:US
Mailing Address - Phone:303-759-0854
Mailing Address - Fax:303-759-0864
Practice Address - Street 1:2525 S DOWNING ST
Practice Address - Street 2:PORTER ADVENTIST HOSPITAL
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80210-5817
Practice Address - Country:US
Practice Address - Phone:303-778-5666
Practice Address - Fax:303-778-5787
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO38678207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO40450040Medicaid
COP00472353OtherRR MEDICARE
CO40450040Medicaid