Basic Information
| Provider Information | |||||||||
| NPI: | 1811132525 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY HEALTH CLINICS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MERCY HEALTH IRVIN PRIMARY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636493 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139815098 | ||||||||
| FaxNumber: | 5139815015 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 RICHMOND ROAD | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403367231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067237706 | ||||||||
| FaxNumber: | 6067269410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2008 | ||||||||
| LastUpdateDate: | 05/02/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STOCKER | ||||||||
| AuthorizedOfficialFirstName: | TRENA | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8597790148 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MARCUM AND WALLACE MEMORIAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 900224 | KY | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 7100132150 | 05 | KY | MEDICAID | 000000652248 | 01 | KY | ANTHEM | OTHER | DQ5374 | 01 | KY | RAILROAD MEDICARE | OTHER |