=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295900165
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MONTE G. MERRELL M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2008
-----------------------------------------------------
Last Update Date | 01/28/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 W. WHITE MOUNTAIN BLVD. SUITE D
-----------------------------------------------------
City | LAKESIDE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85929-7014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-368-4547
-----------------------------------------------------
Fax | 928-368-4527
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 W. WHITE MOUNTAIN BLVD. SUITE D
-----------------------------------------------------
City | LAKESIDE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85929-7014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-368-4547
-----------------------------------------------------
Fax | 928-368-4527
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 107866
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 58018
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------