Healthcare Provider Details

I. General information

NPI: 1316268154
Provider Name (Legal Business Name): MERRITT MEDICAL & PROFESSIONAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2010
Last Update Date: 06/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 CRYSTAL VALLEY CT SE
CALEDONIA MI
49316-8118
US

IV. Provider business mailing address

1511 CRYSTAL VALLEY CT SE
CALEDONIA MI
49316-8118
US

V. Phone/Fax

Practice location:
  • Phone: 616-656-3199
  • Fax: 616-656-3199
Mailing address:
  • Phone: 616-656-3199
  • Fax: 616-656-3199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number4301069990
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number4301069990
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number4301069990
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number4301069990
License Number StateMI

VIII. Authorized Official

Name: CARLOS SCOTT MERRITT
Title or Position: PHYSICIAN/OWNER
Credential: M.D.
Phone: 616-656-3199