Provider Demographics
NPI:1659403038
Name:FAUSETT, MERLIN BARDETT (MD)
Entity Type:Individual
Prefix:DR
First Name:MERLIN
Middle Name:BARDETT
Last Name:FAUSETT
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 1:3405 RAVENWOOD LN
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59803-3219
Mailing Address - Country:US
Mailing Address - Phone:406-360-7941
Mailing Address - Fax:
Practice Address - Street 1:2831 FORT MISSOULA RD STE 232
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7479
Practice Address - Country:US
Practice Address - Phone:406-523-5650
Practice Address - Fax:855-823-5532
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-11
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT336166-1205207V00000X, 207VC0200X
LAMD.13790R207VM0101X
MT30616207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VC0200XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1126148-00Medicaid
UT87041014401Medicaid