Provider Demographics
NPI:1013284637
Name:MERRIMACK MEDICAL & WALK IN S LLC
Entity Type:Organization
Organization Name:MERRIMACK MEDICAL & WALK IN S LLC
Other - Org Name:MERRIMACK MEDICAL & WALK IN CENTER LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:
Authorized Official - Last Name:MICHAUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-688-3100
Mailing Address - Street 1:25 MARSTON ST
Mailing Address - Street 2:STE 304
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01841
Mailing Address - Country:US
Mailing Address - Phone:978-688-3100
Mailing Address - Fax:978-688-3133
Practice Address - Street 1:25 MARSTON ST
Practice Address - Street 2:STE 304
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01841
Practice Address - Country:US
Practice Address - Phone:978-688-3100
Practice Address - Fax:978-688-3133
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERRIMACK MEDICAL & WALK IN CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-28
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110088094AMedicaid
0020668Medicare PIN