Basic Information
Provider Information | |||||||||
NPI: | 1366542771 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MERCY MEMORIAL HOSPITAL CORPORATIO | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1070 N. MONROE ST. | ||||||||
Address2: |   | ||||||||
City: | MONROE | ||||||||
State: | MI | ||||||||
PostalCode: | 48162 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7342408940 | ||||||||
FaxNumber: | 7342408950 | ||||||||
Practice Location | |||||||||
Address1: | 1070 N. MONROE ST | ||||||||
Address2: |   | ||||||||
City: | MONROE | ||||||||
State: | MI | ||||||||
PostalCode: | 48162 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7342404440 | ||||||||
FaxNumber: | 7342404450 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/25/2006 | ||||||||
LastUpdateDate: | 01/18/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SCHILLING | ||||||||
AuthorizedOfficialFirstName: | THOMAS | ||||||||
AuthorizedOfficialMiddleName: | W | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 7342401770 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 583513 | MI | Y |   | Agencies | Hospice Care, Community Based |   |
ID Information
ID | Type | State | Issuer | Description | 3222414 | 05 | MI |   | MEDICAID |