Basic Information
| Provider Information | |||||||||
| NPI: | 1336246784 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERCY MEMORIAL HOSPITAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 718 N MACOMB ST | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481627815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342404440 | ||||||||
| FaxNumber: | 7342404450 | ||||||||
| Practice Location | |||||||||
| Address1: | 718 N MACOMB ST | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481627815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342404440 | ||||||||
| FaxNumber: | 7342404450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 09/28/2010 | ||||||||
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| AuthorizedOfficialLastName: | PHILLIPS | ||||||||
| AuthorizedOfficialFirstName: | ANNETTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7342404570 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 580030 | MI | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 00060 | 01 | MI | BLUE CROSS | OTHER | 1555600 | 05 | MI | MEDICAID |