Provider Demographics
NPI:1619921202
Name:MERIDIAN ADULT MEDICINE, PLLC
Entity Type:Organization
Organization Name:MERIDIAN ADULT MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:SCHLICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-884-3770
Mailing Address - Street 1:520 S EAGLE RD
Mailing Address - Street 2:SUITE 1221
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6351
Mailing Address - Country:US
Mailing Address - Phone:208-884-3770
Mailing Address - Fax:208-884-5602
Practice Address - Street 1:520 S EAGLE RD
Practice Address - Street 2:SUITE 1221
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6351
Practice Address - Country:US
Practice Address - Phone:208-884-3770
Practice Address - Fax:208-884-5602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7522207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8J810OtherBLUE CROSS GROUP
IDDC8105OtherRAILROAD MEDICARE GROUP
ID8J810OtherBLUE CROSS GROUP