Basic Information
| Provider Information | |||||||||
| NPI: | 1659558765 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERCY MEMORIAL HOSPITAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 718 N MACOMB ST | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481627815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342401440 | ||||||||
| FaxNumber: | 7342401550 | ||||||||
| Practice Location | |||||||||
| Address1: | 718 N MACOMB ST | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481627815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342401440 | ||||||||
| FaxNumber: | 7342401550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2008 | ||||||||
| LastUpdateDate: | 01/31/2008 | ||||||||
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| AuthorizedOfficialLastName: | KHAGHNAY | ||||||||
| AuthorizedOfficialFirstName: | KIANOUSH | ||||||||
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| AuthorizedOfficialTitleorPosition: | GROUP REP | ||||||||
| AuthorizedOfficialTelephone: | 7342401442 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MERCY MEMORIAL OB SERVICES | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0E81076 | 01 | MI | BLUE CROSS | OTHER |