Basic Information
| Provider Information | |||||||||
| NPI: | 1316994734 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY HEALTH - TIFFIN HOSPITAL LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HARNESS HEALTH PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 639922 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452639922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194557000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 45 ST LAWRENCE DR | ||||||||
| Address2: | |||||||||
| City: | TIFFIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448838310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194557000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 01/13/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RALSTON | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SYSTEM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4199965119 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | OH | N | Hospital Units | Medicare Defined Swing Bed Unit | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 5887723 | 05 | OH | MEDICAID |