Healthcare Provider Details

I. General information

NPI: 1891895777
Provider Name (Legal Business Name): TARA ANN MERRITT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 10/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1181 LANGFORD DR BLDG 200 SUITE 101
WATKINSVILLE GA
30677-7242
US

IV. Provider business mailing address

1181 LANGFORD DRIVE BLDG 200 SUITE 101
WATKINSVILLE GA
30677
US

V. Phone/Fax

Practice location:
  • Phone: 706-850-8750
  • Fax: 706-850-8760
Mailing address:
  • Phone: 706-850-8750
  • Fax: 706-850-8760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number58543
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number58543
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number58543
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: