Healthcare Provider Details

I. General information

NPI: 1063490001
Provider Name (Legal Business Name): MERLIN W FRIESEN IV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 CHERRY ST
PAOLI IN
47454-1108
US

IV. Provider business mailing address

75 E COUNTY ROAD 250 S
PAOLI IN
47454-9341
US

V. Phone/Fax

Practice location:
  • Phone: 812-723-3386
  • Fax:
Mailing address:
  • Phone: 812-723-3386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01044639
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: