Provider Demographics
NPI:1457434896
Name:MERCHUT, MICHAEL P (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:MERCHUT
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 1:2160 S FIRST AVE
Mailing Address - Street 2:(MAGUIRE CENTER, RM. 2700)
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153
Mailing Address - Country:US
Mailing Address - Phone:708-216-2662
Mailing Address - Fax:708-216-5617
Practice Address - Street 1:2160 S FIRST AVE
Practice Address - Street 2:(MAGUIRE CENTER, RM. 2700)
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-216-2662
Practice Address - Fax:708-216-5617
Is Sole Proprietor?:No
Enumeration Date:2006-10-21
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360611212084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D15727Medicare UPIN
L80530Medicare ID - Type Unspecified