Basic Information
| Provider Information | |||||||||
| NPI: | 1487674297 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY HEALTH-ST RITAS MEDICAL CENTER LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | DELPHOS AMBULATORY CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 951999 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441930021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196922662 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1800 E 5TH ST | ||||||||
| Address2: | |||||||||
| City: | DELPHOS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458339139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196922662 | ||||||||
| FaxNumber: | 4199965458 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 01/13/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RALSTON | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SYSTEM | ||||||||
| AuthorizedOfficialTelephone: | 4199965119 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 2412811 | 05 | OH | MEDICAID |