Basic Information
Provider Information | |||||||||
NPI: | 1629011234 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MERCY HEALTH - DEFIANCE HOSPITAL LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MERCY HEALTH - DEFIANCE HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 636524 | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452636524 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4197828444 | ||||||||
FaxNumber: | 4192512109 | ||||||||
Practice Location | |||||||||
Address1: | 1404 E 2ND ST | ||||||||
Address2: |   | ||||||||
City: | DEFIANCE | ||||||||
State: | OH | ||||||||
PostalCode: | 435122440 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4197828444 | ||||||||
FaxNumber: | 4192512109 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2006 | ||||||||
LastUpdateDate: | 03/02/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SELHORST | ||||||||
AuthorizedOfficialFirstName: | SONYA | ||||||||
AuthorizedOfficialMiddleName: | SUE | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR OFFICER DEFIANCE | ||||||||
AuthorizedOfficialTelephone: | 4197853983 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/02/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X |   |   | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 2530309 | 05 | OH |   | MEDICAID | 000000344458 | 01 | OH | ANTHEM | OTHER |