Basic Information
| Provider Information | |||||||||
| NPI: | 1760673495 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERCY HEALTH - ST VINCENT MEDICAL CENTER LLC | ||||||||
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| OtherOrganizationName: | ST VINCENT PAIN CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 JEFFERSON AVE | ||||||||
| Address2: | 4TH FL | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436047101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192518983 | ||||||||
| FaxNumber: | 4192516719 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 CHERRY ST | ||||||||
| Address2: | SUITE M800 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436082673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192513292 | ||||||||
| FaxNumber: | 4192517821 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2007 | ||||||||
| LastUpdateDate: | 01/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | PLATZKE | ||||||||
| AuthorizedOfficialFirstName: | SAMANTHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4192510722 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7649905 | 05 | OH | MEDICAID |