Basic Information
| Provider Information | |||||||||
| NPI: | 1326023748 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MERRY | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 ENTERPRISE DR | ||||||||
| Address2: | |||||||||
| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605238813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305756200 | ||||||||
| FaxNumber: | 6309285080 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 WESTERVILLE PLZ | ||||||||
| Address2: | |||||||||
| City: | WESTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430812882 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147918015 | ||||||||
| FaxNumber: | 6147943552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT 003963 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2614488 | 05 | OH | MEDICAID | 311356625029 | 01 | OH | CARESOURCE MCO | OTHER | 000000372031 | 01 | OH | ANTHEM PROVIDER NUMBER | OTHER | 23-2804807 | 01 | OH | REHAB PROVIDER NETWORK | OTHER | 31-1356625 | 01 | OH | GREAT WEST PROVIDER NUMBE | OTHER | 685840 | 01 | OH | UHC | OTHER | 9400939 | 01 | OH | PHCS NETWORK | OTHER | 11648861 | 01 | OH | CAQH NUMBER | OTHER |