Basic Information
Provider Information | |||||||||
NPI: | 1821039009 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MERRICK | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 905 | ||||||||
Address2: |   | ||||||||
City: | ST JOHNSBURY | ||||||||
State: | VT | ||||||||
PostalCode: | 058190905 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8027488141 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1315 HOSPITAL DR | ||||||||
Address2: |   | ||||||||
City: | ST JOHNSBURY | ||||||||
State: | VT | ||||||||
PostalCode: | 058199210 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8027488141 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/09/2006 | ||||||||
LastUpdateDate: | 09/02/2014 | ||||||||
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 | 7881 | NH | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | 042-0011819 | VT | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 19122 | 01 | VT | BLUE CROSS BLUE SHIELD | OTHER | 541411 | 01 | NH | CIGNA HEALTHCARE | OTHER | E11292 | 01 | NH | HARVARD PILGRIM HEALTH | OTHER | ORE0315 | 05 | VT |   | MEDICAID | 0104375Y0NH01 | 01 | NH | BLUE CROSS BLUE SHIELD | OTHER | 3075605 | 05 | NH |   | MEDICAID |