Provider Demographics
NPI:1528129301
Name:SHIDLER, MERRILL J (MD)
Entity type:Individual
Prefix:
First Name:MERRILL
Middle Name:J
Last Name:SHIDLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2601 MISSION POINT BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-6600
Mailing Address - Country:US
Mailing Address - Phone:937-912-4441
Mailing Address - Fax:937-429-4236
Practice Address - Street 1:1068 STATE ROUTE 28
Practice Address - Street 2:SUITE C
Practice Address - City:MILFORD
Practice Address - State:OH
Practice Address - Zip Code:45150-2095
Practice Address - Country:US
Practice Address - Phone:513-831-5900
Practice Address - Fax:513-831-0354
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35051246207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0567515Medicaid
OH4118945Medicare PIN
OH0567515Medicaid
OHSH4118944Medicare ID - Type UnspecifiedIND MEDICARE