Basic Information
| Provider Information | |||||||||
| NPI: | 1023347192 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY HEALTH PHYSICIANS LORAIN, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TRI-CITY MEDICAL SERVICES, LLC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 MERCY HEALTH PL | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452376147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409881009 | ||||||||
| FaxNumber: | 4409600264 | ||||||||
| Practice Location | |||||||||
| Address1: | 3700 KOLBE RD | ||||||||
| Address2: | |||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440531611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409881009 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2009 | ||||||||
| LastUpdateDate: | 02/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | DACRE | ||||||||
| AuthorizedOfficialFirstName: | OLIVIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO, MEDICAL GROUP | ||||||||
| AuthorizedOfficialTelephone: | 4192519650 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207UN0901X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | 207VG0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207RG0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3025372 | 05 | OH | MEDICAID |