Provider Demographics
NPI:1942342431
Name:MERRELL, KARSTAN I (CO)
Entity Type:Individual
Prefix:MR
First Name:KARSTAN
Middle Name:I
Last Name:MERRELL
Suffix:
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 BRAINERD RD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37411-3603
Mailing Address - Country:US
Mailing Address - Phone:423-697-0057
Mailing Address - Fax:423-697-0666
Practice Address - Street 1:3700 BRAINERD RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37411-3603
Practice Address - Country:US
Practice Address - Phone:423-697-0057
Practice Address - Fax:423-697-0666
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1455062Medicaid
1254770002Medicare ID - Type Unspecified