Basic Information
| Provider Information | |||||||||
| NPI: | 1669702106 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST MARGARET MERCY HEALTHCARE CENTERS, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EAR NOSE AND THROAT CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1000 | ||||||||
| Address2: | |||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463110800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198642268 | ||||||||
| FaxNumber: | 2198642649 | ||||||||
| Practice Location | |||||||||
| Address1: | 24 JOLIET ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463111705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198642059 | ||||||||
| FaxNumber: | 2198642644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2010 | ||||||||
| LastUpdateDate: | 01/06/2010 | ||||||||
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| AuthorizedOfficialLastName: | MAPLE | ||||||||
| AuthorizedOfficialFirstName: | HEATHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 2199322300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YX0905X | 02000967A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngology/Facial Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200504980 | 05 | IN | MEDICAID |