=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063490001
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MERLIN W FRIESEN IV M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 202 CHERRY ST
-----------------------------------------------------
City | PAOLI
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47454-1108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-723-3386
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 75 E COUNTY ROAD 250 S
-----------------------------------------------------
City | PAOLI
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47454-9341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-723-3386
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 01044639
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------