=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316268154
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MERRITT MEDICAL & PROFESSIONAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2010
-----------------------------------------------------
Last Update Date | 06/16/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1511 CRYSTAL VALLEY CT SE
-----------------------------------------------------
City | CALEDONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49316-8118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-656-3199
-----------------------------------------------------
Fax | 616-656-3199
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1511 CRYSTAL VALLEY CT SE
-----------------------------------------------------
City | CALEDONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49316-8118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-656-3199
-----------------------------------------------------
Fax | 616-656-3199
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN/OWNER
-----------------------------------------------------
Name | CARLOS SCOTT MERRITT
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 616-656-3199
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number | 4301069990
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | 4301069990
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | 4301069990
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number | 4301069990
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------