Provider Demographics
NPI:1699871038
Name:MERRIMAN, PATRICIA
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:MERRIMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1653 W CONGRESS PKWY
Mailing Address - Street 2:735 JELKE ANESTHESIA DEPARTMENT
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3833
Mailing Address - Country:US
Mailing Address - Phone:312-942-6631
Mailing Address - Fax:312-942-5773
Practice Address - Street 1:1653 W CONGRESS PKWY
Practice Address - Street 2:735 JELKE ANESTHESIA DEPARTMENT
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3833
Practice Address - Country:US
Practice Address - Phone:312-942-6631
Practice Address - Fax:312-942-5773
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-0006613103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILPOO212259OtherMEDICARE RAILROAD NUMBER
ILK14722Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER