Healthcare Provider Details

I. General information

NPI: 1144529769
Provider Name (Legal Business Name): SAMUEL MERRILL MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2011
Last Update Date: 04/08/2022
Certification Date: 04/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 MEDICAL CENTER DRIVE
MORGANTOWN WV
26506
US

IV. Provider business mailing address

64 MEDICAL CENTER DRIVE BOX 9162
MORGANTOWN WV
26506-9162
US

V. Phone/Fax

Practice location:
  • Phone: 304-598-6984
  • Fax: 304-598-4560
Mailing address:
  • Phone:
  • Fax: 304-598-4560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0420012849
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License NumberD0097056
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number29029
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: