Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | IL |
NPI | 1386764348 |
---|---|
Provider Name | Dr. Mark A. Merz |
First Address | Edwardsville, IL 62025-4281 |
Second Address | Edwardsville, IL 62025-4281 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/03/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0006005107 | BCBS PROVIDER # (01) | IL |