=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538140926
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MERITAS SURGICAL, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2005
-----------------------------------------------------
Last Update Date | 08/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1970 TAMARACK RD
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43055-1363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-344-2452
-----------------------------------------------------
Fax | 740-344-7305
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1970 TAMARACK RD
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43055-1363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-344-2452
-----------------------------------------------------
Fax | 740-344-7305
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT, CORPORATION
-----------------------------------------------------
Name | DR. ALEX D JUAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 740-344-2452
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 48932
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------