Basic Information
Provider Information | |||||||||
NPI: | 1528006483 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WARD | ||||||||
FirstName: | MERRILL | ||||||||
MiddleName: | CRAIG | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13101 INDIAN TRAIL RD | ||||||||
Address2: |   | ||||||||
City: | GENESEO | ||||||||
State: | IL | ||||||||
PostalCode: | 612549068 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3097929363 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 801 ILLINI DR | ||||||||
Address2: |   | ||||||||
City: | SILVIS | ||||||||
State: | IL | ||||||||
PostalCode: | 612821804 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3097929363 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/03/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X |   | IL | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 96939 | 01 | IA | BLUE CROSS BLUE SHIELD | OTHER | C68730 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER | 054347 | 01 |   | HEALTH ALLIANCE | OTHER | C68730 | 01 |   | TRICARE | OTHER |