Basic Information
| Provider Information | |||||||||
| NPI: | 1528078110 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MYERLY | ||||||||
| FirstName: | JIM | ||||||||
| MiddleName: | IRVING | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5126 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053351952 | ||||||||
| FaxNumber: | 6053739971 | ||||||||
| Practice Location | |||||||||
| Address1: | 1018 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | WORTHINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 561872202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073723165 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 02/21/2013 | ||||||||
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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 | 2085R0202X | 27174 | MN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 22238 | IA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 30086653 | 01 | MN | RAILROAD MEDICARE | OTHER |