Healthcare Provider Details

I. General information

NPI: 1356460976
Provider Name (Legal Business Name): GAIL ANN MERRILL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 06/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 CHERRY ST.
GRAND RAPIDS MI
49506
US

IV. Provider business mailing address

822 CHERRY ST.
GRAND RAPIDS MI
49506
US

V. Phone/Fax

Practice location:
  • Phone: 616-776-0891
  • Fax: 616-233-0689
Mailing address:
  • Phone: 616-776-0891
  • Fax: 616-233-0689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601003749
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: