Provider Demographics
NPI:1679779011
Name:BRADFORD MERRELLI MD PC
Entity Type:Organization
Organization Name:BRADFORD MERRELLI MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADFORD
Authorized Official - Middle Name:J
Authorized Official - Last Name:MERRELLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-852-5355
Mailing Address - Street 1:595 BARCLAY CIR
Mailing Address - Street 2:SUITE D
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-5802
Mailing Address - Country:US
Mailing Address - Phone:248-852-5355
Mailing Address - Fax:248-852-8411
Practice Address - Street 1:595 BARCLAY CIR
Practice Address - Street 2:SUITE D
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-5802
Practice Address - Country:US
Practice Address - Phone:248-852-5355
Practice Address - Fax:248-852-8411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301048826207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0631383Medicare ID - Type Unspecified
MIA77959Medicare UPIN