Basic Information
Provider Information | |||||||||
NPI: | 1861636540 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MERCY MEMORIAL HOSPITAL CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MOOSA | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 718 N MACOMB ST | ||||||||
Address2: |   | ||||||||
City: | MONROE | ||||||||
State: | MI | ||||||||
PostalCode: | 481627815 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7342408840 | ||||||||
FaxNumber: | 7342404450 | ||||||||
Practice Location | |||||||||
Address1: | 718 N MACOMB ST | ||||||||
Address2: |   | ||||||||
City: | MONROE | ||||||||
State: | MI | ||||||||
PostalCode: | 481627815 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7342408840 | ||||||||
FaxNumber: | 7342404450 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/27/2009 | ||||||||
LastUpdateDate: | 04/27/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PHILLIPS | ||||||||
AuthorizedOfficialFirstName: | ANNETTE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 7342408840 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | 4301081240 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
ID | Type | State | Issuer | Description | 080E812180 | 01 | MI | BLUE CROSS | OTHER |