Provider Demographics
NPI:1942243811
Name:BRANDT, MERRILEE R (MD)
Entity Type:Individual
Prefix:
First Name:MERRILEE
Middle Name:R
Last Name:BRANDT
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 1:1054 MARTIN LUTHER KING DR
Mailing Address - Street 2:SUITE 125
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-3000
Mailing Address - Country:US
Mailing Address - Phone:618-436-5200
Mailing Address - Fax:618-436-8066
Practice Address - Street 1:1054 MARTIN LUTHER KING DR
Practice Address - Street 2:SUITE 125
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3000
Practice Address - Country:US
Practice Address - Phone:618-436-5200
Practice Address - Fax:618-436-8066
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036100456208600000X
MI4301064187174400000X
ND11827208600000X
OK27935208600000X
KS0433646208600000X
MO2009002719208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036100456Medicaid
ILF400196136Medicare PIN
IL036100456Medicaid
IL207988053Medicare PIN