Provider Demographics
NPI:1366410292
Name:MERCHANT, GHULAM A (MD)
Entity type:Individual
Prefix:DR
First Name:GHULAM
Middle Name:A
Last Name:MERCHANT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-3001
Mailing Address - Country:US
Mailing Address - Phone:618-532-3110
Mailing Address - Fax:618-532-7226
Practice Address - Street 1:1045 MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3001
Practice Address - Country:US
Practice Address - Phone:618-532-3110
Practice Address - Fax:618-532-7226
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
938950Medicare ID - Type UnspecifiedMEDICARE
B82845Medicare UPIN