Basic Information
| Provider Information | |||||||||
| NPI: | 1851599831 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MERRITT | ||||||||
| FirstName: | MINDY | ||||||||
| MiddleName: | LEE NACE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NACE | ||||||||
| OtherFirstName: | MINDY | ||||||||
| OtherMiddleName: | LEE | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3714 GUARDIAN AVE | ||||||||
| Address2: | SUITE E | ||||||||
| City: | MOREHEAD CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285572974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522472101 | ||||||||
| FaxNumber: | 2522474675 | ||||||||
| Practice Location | |||||||||
| Address1: | 3714 GUARDIAN AVE | ||||||||
| Address2: | SUITE E | ||||||||
| City: | MOREHEAD CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285572974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522472101 | ||||||||
| FaxNumber: | 2522474675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2007 | ||||||||
| LastUpdateDate: | 09/04/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 141282 | NC | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1714P | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER | 5920642 | 05 | NC | MEDICAID | P01312592 | 01 | NC | RR MEDICARE | OTHER |