Healthcare Provider Details

I. General information

NPI: 1144661448
Provider Name (Legal Business Name): JOSEPH E. MERRYWEATHER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2013
Last Update Date: 07/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 W LAKE ST
MELROSE PARK IL
60160-4039
US

IV. Provider business mailing address

2000 SPRING RD SUITE 200
OAK BROOK IL
60523-1804
US

V. Phone/Fax

Practice location:
  • Phone: 708-938-7209
  • Fax:
Mailing address:
  • Phone: 630-472-8800
  • Fax: 630-472-9502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.004697
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: