Healthcare Provider Details

I. General information

NPI: 1134306947
Provider Name (Legal Business Name): GERALD PAUL MYERS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2008
Last Update Date: 01/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 PARK ROW
MICHIGAN CITY IN
46360
US

IV. Provider business mailing address

54354 OLD BEDFORD TRL
MISHAWAKA IN
46545-1513
US

V. Phone/Fax

Practice location:
  • Phone: 219-874-7256
  • Fax: 219-879-9839
Mailing address:
  • Phone: 219-874-7256
  • Fax: 219-879-9839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number01025704
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: