Basic Information
| Provider Information | |||||||||
| NPI: | 1770703910 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERCY HEALTH-ST RITAS MEDICAL CENTER LLC | ||||||||
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| OtherOrganizationName: | NEW CENTURY PEDIATRICS GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 931325 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441931517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199965114 | ||||||||
| FaxNumber: | 4192269831 | ||||||||
| Practice Location | |||||||||
| Address1: | 730 W MARKET ST | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458014602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192269585 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2007 | ||||||||
| LastUpdateDate: | 01/13/2022 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4199965119 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0204X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0809450 | 05 | OH | MEDICAID |