Healthcare Provider Details

I. General information

NPI: 1205824067
Provider Name (Legal Business Name): MERRILL RALPH NISAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 LARKSPUR LANDING CIR STE 10
LARKSPUR CA
94939-1836
US

IV. Provider business mailing address

1100 LARKSPUR LANDING CIR STE 10
LARKSPUR CA
94939-1836
US

V. Phone/Fax

Practice location:
  • Phone: 415-924-1214
  • Fax: 415-924-1375
Mailing address:
  • Phone: 415-924-1214
  • Fax: 415-924-1375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberA45217
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA45217
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: