Basic Information
| Provider Information | |||||||||
| NPI: | 1689648719 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MERRY | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | GORDON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1520 VIRGINIA RANCH RD | ||||||||
| Address2: | |||||||||
| City: | GARDNERVILLE | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894105731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757821550 | ||||||||
| FaxNumber: | 7757821513 | ||||||||
| Practice Location | |||||||||
| Address1: | 1649 LUCERNE ST | ||||||||
| Address2: | STE A & B | ||||||||
| City: | MINDEN | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894234369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757821603 | ||||||||
| FaxNumber: | 7757823417 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 04/22/2009 | ||||||||
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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 | 7634 | NV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 002003030 | 05 | NV | MEDICAID | 003103030 | 05 | NV | MEDICAID |