Healthcare Provider Details

I. General information

NPI: 1194791962
Provider Name (Legal Business Name): MERRY MEDICAL TEAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1649 LUCERNE ST STE A & B
MINDEN NV
89423-4363
US

IV. Provider business mailing address

1111 EMERALD BAY RD
SOUTH LAKE TAHOE CA
96150-6207
US

V. Phone/Fax

Practice location:
  • Phone: 775-782-1603
  • Fax: 775-782-3427
Mailing address:
  • Phone: 530-543-5659
  • Fax: 530-541-8723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNV

VIII. Authorized Official

Name: THOMAS GORDON MERRY
Title or Position: PRESIDENT
Credential: MD
Phone: 775-782-1603