Basic Information
| Provider Information | |||||||||
| NPI: | 1861818379 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY HEALTH PARTNERS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | MHP LAKESHORE MED PLUS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 905 E COLBY ST | ||||||||
| Address2: | |||||||||
| City: | WHITEHALL | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494611262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317285910 | ||||||||
| FaxNumber: | 2317285918 | ||||||||
| Practice Location | |||||||||
| Address1: | 905 E COLBY ST | ||||||||
| Address2: | |||||||||
| City: | WHITEHALL | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494611262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317285910 | ||||||||
| FaxNumber: | 2317285918 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2014 | ||||||||
| LastUpdateDate: | 04/04/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRYAN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2318613030 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MERCY HEALTH PARTNERS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.