Provider Demographics
NPI:1528078110
Name:MYERLY, JIM IRVING (MD)
Entity type:Individual
Prefix:MR
First Name:JIM
Middle Name:IRVING
Last Name:MYERLY
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:PO BOX 5126
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5126
Mailing Address - Country:US
Mailing Address - Phone:605-335-1952
Mailing Address - Fax:605-373-9971
Practice Address - Street 1:1018 6TH AVE
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:MN
Practice Address - Zip Code:56187-2202
Practice Address - Country:US
Practice Address - Phone:507-372-3165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN271742085R0202X
IA222382085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN30086653OtherRAILROAD MEDICARE
D86723Medicare UPIN
MN30900553Medicare PIN
IA1906Medicare PIN