Provider Demographics
NPI:1629019724
Name:SHERRILL, MONIQUE M (MD)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:M
Last Name:SHERRILL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 DRIVER LN NW
Mailing Address - Street 2:
Mailing Address - City:FORT PAYNE
Mailing Address - State:AL
Mailing Address - Zip Code:35967-8212
Mailing Address - Country:US
Mailing Address - Phone:256-997-3434
Mailing Address - Fax:
Practice Address - Street 1:1202 GAULT AVE N
Practice Address - Street 2:
Practice Address - City:FORT PAYNE
Practice Address - State:AL
Practice Address - Zip Code:35967-3040
Practice Address - Country:US
Practice Address - Phone:256-997-3434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19961208000000X
OH35-07-6408208000000X
ALMD.33738207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000181880OtherUNISON MEDICAID #
OH2124507Medicaid
OH310917085071OtherCARESOURCE MEDICAID #
001714111OtherMOUNTAIN STATE BCBS
000000504768OtherANTHEM BCBS
OH2124507OtherMOLINA MEDICAID #
OH370013973OtherRR MEDICARE
WV6700078000Medicaid
G84120Medicare UPIN
WV6700078000Medicaid
OH2124507Medicaid