Basic Information
| Provider Information | |||||||||
| NPI: | 1265605240 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERCY HEALTH - WILLARD HOSPITAL LLC | ||||||||
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| OtherOrganizationName: | SISTER OF MERCY OF WILLARD, OHIO | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 JEFFERSON AVE | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436047101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192518997 | ||||||||
| FaxNumber: | 4192513553 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 E HOWARD ST | ||||||||
| Address2: | |||||||||
| City: | WILLARD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448901611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199645000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2008 | ||||||||
| LastUpdateDate: | 09/02/2014 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP | ||||||||
| AuthorizedOfficialTelephone: | 4192269117 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 2692368 | 05 | OH | MEDICAID |