Basic Information
| Provider Information | |||||||||
| NPI: | 1528129301 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIDLER | ||||||||
| FirstName: | MERRILL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2601 MISSION POINT BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BEAVERCREEK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454316600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379124441 | ||||||||
| FaxNumber: | 9374294236 | ||||||||
| Practice Location | |||||||||
| Address1: | 1068 STATE ROUTE 28 | ||||||||
| Address2: | SUITE C | ||||||||
| City: | MILFORD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451502095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138315900 | ||||||||
| FaxNumber: | 5138310354 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 11/27/2012 | ||||||||
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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 | 207Q00000X | 35051246 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0567515 | 05 | OH | MEDICAID |