Basic Information
| Provider Information | |||||||||
| NPI: | 1427165570 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERCY ANESTHESIOLOGISTS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2790 KILKENNY DR | ||||||||
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| City: | SPRINGFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 455031181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373997164 | ||||||||
| FaxNumber: | 9377175370 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 W MAIN ST | ||||||||
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| City: | SPRINGFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 455021312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375213900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 02/15/2013 | ||||||||
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| AuthorizedOfficialLastName: | PAVLATOS | ||||||||
| AuthorizedOfficialFirstName: | THALES | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9373997164 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 0201347 | 05 | OH | MEDICAID |