Provider Demographics
NPI:1831161058
Name:MERRELL, MICHAEL GERALD (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GERALD
Last Name:MERRELL
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 1:412 EDWARDS RD
Mailing Address - Street 2:
Mailing Address - City:NEW KENSINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15068-9226
Mailing Address - Country:US
Mailing Address - Phone:724-212-1066
Mailing Address - Fax:
Practice Address - Street 1:412 EDWARDS RD
Practice Address - Street 2:
Practice Address - City:NEW KENSINGTON
Practice Address - State:PA
Practice Address - Zip Code:15068-9226
Practice Address - Country:US
Practice Address - Phone:724-212-1066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18595207Q00000X
AL26072207Q00000X
PAMD441377207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1782254Medicaid
MS01632897Medicaid
P00272261OtherRAILROAD MEDICARE
MSI26153Medicare UPIN
LA1782254Medicaid