Basic Information
| Provider Information | |||||||||
| NPI: | 1285632109 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY HEALTH-MARCUM & WALLACE HOSPITAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 60 MERCY CT | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403361331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067232115 | ||||||||
| FaxNumber: | 6067232951 | ||||||||
| Practice Location | |||||||||
| Address1: | 60 MERCY CT | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403361331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067232115 | ||||||||
| FaxNumber: | 6067232951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | STOCKER | ||||||||
| AuthorizedOfficialFirstName: | TRENA | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8597790148 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 01/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | KY | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 01002526 | 05 | KY | MEDICAID |