Healthcare Provider Details

I. General information

NPI: 1740299650
Provider Name (Legal Business Name): FREDERICK A. MERRILL III D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 N BELAIR RD SUITE 1C
EVANS GA
30809-3188
US

IV. Provider business mailing address

465 N BELAIR RD SUITE 1C
EVANS GA
30809-3188
US

V. Phone/Fax

Practice location:
  • Phone: 706-854-2160
  • Fax: 706-854-2930
Mailing address:
  • Phone: 706-854-2160
  • Fax: 706-854-2930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number034664
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: