Basic Information
Provider Information | |||||||||
NPI: | 1194919324 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MERCY MEDICAL PARTNERS NORTHERN REIGON LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MERCY MEDICAL PARTNERS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2200 JEFFERSON AVE FL 4 | ||||||||
Address2: |   | ||||||||
City: | TOLEDO | ||||||||
State: | OH | ||||||||
PostalCode: | 436047102 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4192518983 | ||||||||
FaxNumber: | 4192516719 | ||||||||
Practice Location | |||||||||
Address1: | 1400 E 2ND ST | ||||||||
Address2: |   | ||||||||
City: | DEFIANCE | ||||||||
State: | OH | ||||||||
PostalCode: | 435122440 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4197841414 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/30/2007 | ||||||||
LastUpdateDate: | 04/09/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MONTAGUE | ||||||||
AuthorizedOfficialFirstName: | MICHELE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT/ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 4192510709 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X |   |   | Y |   | Laboratories | Clinical Medical Laboratory |   |
No ID Information.