Provider Demographics
NPI:1770096430
Name:MERKLEY MIDWEST - OHIO, P.A.
Entity type:Organization
Organization Name:MERKLEY MIDWEST - OHIO, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INTERNAL LEGAL AGENT / CREDENTIALER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-550-6421
Mailing Address - Street 1:19 W MARKET ST STE A
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-2772
Mailing Address - Country:US
Mailing Address - Phone:419-447-9541
Mailing Address - Fax:419-447-1223
Practice Address - Street 1:19 W MARKET ST STE A
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-2772
Practice Address - Country:US
Practice Address - Phone:419-447-9541
Practice Address - Fax:419-447-1223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-15
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9045508-99221223G0001X
1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty