Basic Information
| Provider Information | |||||||||
| NPI: | 1700806023 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVERSIDE MERCY HOSPITAL | ||||||||
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| OtherOrganizationName: | ST ANNE MERCY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 JEFFERSON AVE | ||||||||
| Address2: | 4TH FL | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436241120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192518997 | ||||||||
| FaxNumber: | 4192513553 | ||||||||
| Practice Location | |||||||||
| Address1: | 3404 W SYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436234467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194072663 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 04/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | PLATZKE | ||||||||
| AuthorizedOfficialFirstName: | SAMATHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4192512046 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST ANNE MERCY HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2805067 | 05 | OH | MEDICAID |