=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164645214
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLINTON F MERRILL MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 255 N 30TH ST
-----------------------------------------------------
City | LARAMIE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82072-5140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-742-7586
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 255 N 30TH ST
-----------------------------------------------------
City | LARAMIE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82072-5140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-742-7586
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CLINTON F MERRILL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 307-742-7586
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 3277A
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------