Provider Demographics
NPI:1669438784
Name:MERRILL, JEFFREY R (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:R
Last Name:MERRILL
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:PO BOX 3700
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602-3700
Mailing Address - Country:US
Mailing Address - Phone:423-952-2122
Mailing Address - Fax:423-952-2145
Practice Address - Street 1:1019 W OAKLAND AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2357
Practice Address - Country:US
Practice Address - Phone:423-915-5000
Practice Address - Fax:423-915-5045
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD30902207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1669438784Medicaid
TN3858149Medicaid
VAVV3947AMedicare PIN
VA1669438784Medicaid
TN3858149Medicaid
TN3858141Medicare PIN