Healthcare Provider Details

I. General information

NPI: 1902816895
Provider Name (Legal Business Name): MAX R. MERTZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 01/15/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1814 CHARLTON CT STE A
GOSHEN IN
46526-6463
US

IV. Provider business mailing address

1814 CHARLTON CT STE A
GOSHEN IN
46526-6463
US

V. Phone/Fax

Practice location:
  • Phone: 574-533-4169
  • Fax: 574-534-8822
Mailing address:
  • Phone: 574-533-4169
  • Fax: 574-534-8822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01031930A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: