Basic Information
| Provider Information | |||||||||
| NPI: | 1467482323 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MERIC | ||||||||
| FirstName: | ALBERT | ||||||||
| MiddleName: | LOUIS | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MERIC | ||||||||
| OtherFirstName: | BERT | ||||||||
| OtherMiddleName: | LOUIS | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 16 WALNUT CRK | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926021046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493758996 | ||||||||
| FaxNumber: | 9492091980 | ||||||||
| Practice Location | |||||||||
| Address1: | 3931 LOUISIANA AVE S | ||||||||
| Address2: | SUITE EAST 500 | ||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554264375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529932079 | ||||||||
| FaxNumber: | 9529932701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 10/13/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | MD 018355 | TN | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | 50069 | MN | Y | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | C53082 | CA | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | 10495 | ND | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | E-5123 | AR | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | 38056 | IA | N | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 067463200 | 01 | MN | MN MEDICAL ASSISTANCE | OTHER | 3076786 | 05 | TN | MEDICAID |