Basic Information
| Provider Information | |||||||||
| NPI: | 1497160469 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY HEALTH SERVICES, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MERCY COMMUNITY HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1113 MURFREESBORO RD | ||||||||
| Address2: | STE 319 | ||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370641306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157900567 | ||||||||
| FaxNumber: | 6155958030 | ||||||||
| Practice Location | |||||||||
| Address1: | 1113 MURFREESBORO RD | ||||||||
| Address2: | STE 319 | ||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370641306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157900567 | ||||||||
| FaxNumber: | 6155958030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2014 | ||||||||
| LastUpdateDate: | 06/27/2014 | ||||||||
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| AuthorizedOfficialLastName: | GEORGE | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 6157900567 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 0449156 | 05 | TN | MEDICAID |