Basic Information
| Provider Information | |||||||||
| NPI: | 1124056874 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY HEALTH-REGIONAL MEDICAL CENTER LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | MERCY NEW LIFE HOSPICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 KOLBE RD | ||||||||
| Address2: | |||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440531632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409341458 | ||||||||
| FaxNumber: | 4409603359 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 KOLBE RD | ||||||||
| Address2: | |||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440531632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409341458 | ||||||||
| FaxNumber: | 4409603359 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 04/15/2019 | ||||||||
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| AuthorizedOfficialLastName: | OLEY | ||||||||
| AuthorizedOfficialFirstName: | EDWIN | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 4409603295 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MERCY HEALTH LORAIN LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315D00000X | N | Nursing & Custodial Care Facilities | Hospice, Inpatient | 251G00000X | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 2412197 | 05 | OH | MEDICAID |