Basic Information
| Provider Information | |||||||||
| NPI: | 1558527184 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERCY HEALTH-REGIONAL MEDICAL CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3700 KOLBE RD | ||||||||
| Address2: | ATTN: PRE SERVICE CENTER MANAGER | ||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440531611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409893801 | ||||||||
| FaxNumber: | 4409600264 | ||||||||
| Practice Location | |||||||||
| Address1: | 3700 KOLBE RD | ||||||||
| Address2: | ATTN: PRE SERVICE CENTER MANAGER | ||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440531611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409893801 | ||||||||
| FaxNumber: | 4409600264 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2008 | ||||||||
| LastUpdateDate: | 05/01/2014 | ||||||||
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| AuthorizedOfficialLastName: | OLEY | ||||||||
| AuthorizedOfficialFirstName: | EDWIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 4409604000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 103TA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) | 103TB0200X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TP2701X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | 207PE0004X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 2085R0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 0207207 | 05 | OH | MEDICAID |