Basic Information
Provider Information | |||||||||
NPI: | 1144251489 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MERCY HEALTH PARTNERS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MERCY HEALTH BEHAVIORAL HEALTH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 20555 VICTOR PKWY | ||||||||
Address2: |   | ||||||||
City: | LIVONIA | ||||||||
State: | MI | ||||||||
PostalCode: | 481527031 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7343433925 | ||||||||
FaxNumber: | 3129573997 | ||||||||
Practice Location | |||||||||
Address1: | 125 E SOUTHERN AVE STE 120 | ||||||||
Address2: |   | ||||||||
City: | MUSKEGON | ||||||||
State: | MI | ||||||||
PostalCode: | 494425041 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2316722000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/05/2006 | ||||||||
LastUpdateDate: | 02/14/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ALLORE | ||||||||
AuthorizedOfficialFirstName: | GARY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2317284809 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/14/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | H012/2000 | MI | Y |   | Hospital Units | Psychiatric Unit |   |
ID Information
ID | Type | State | Issuer | Description | 0066 | 05 | MI |   | MEDICAID | 00066 | 01 | MI | BCBSM | OTHER | 1557275 | 05 | MI |   | MEDICAID | 5170747 | 05 | MI |   | MEDICAID |