Provider Demographics
NPI:1194791962
Name:MERRY MEDICAL TEAM
Entity type:Organization
Organization Name:MERRY MEDICAL TEAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:MERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:775-782-1603
Mailing Address - Street 1:1111 EMERALD BAY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6207
Mailing Address - Country:US
Mailing Address - Phone:530-543-5659
Mailing Address - Fax:530-541-8723
Practice Address - Street 1:1649 LUCERNE ST
Practice Address - Street 2:STE A & B
Practice Address - City:MINDEN
Practice Address - State:NV
Practice Address - Zip Code:89423-4363
Practice Address - Country:US
Practice Address - Phone:775-782-1603
Practice Address - Fax:775-782-3427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV207Q00000X
207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100506316Medicaid
NV36234Medicare PIN