Basic Information
| Provider Information | |||||||||
| NPI: | 1881869899 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERCY HEALTH-ST RITAS MEDICAL CENTER LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DELPHOS AMBULATORY CARE PHYSICIAN SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 951999 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441930021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199965114 | ||||||||
| FaxNumber: | 4199965410 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 E 5TH ST | ||||||||
| Address2: | |||||||||
| City: | DELPHOS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458339180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199965030 | ||||||||
| FaxNumber: | 4199965458 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2008 | ||||||||
| LastUpdateDate: | 01/13/2022 | ||||||||
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| AuthorizedOfficialLastName: | RALSTON | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | SYSTEM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4199965119 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2412811 | 05 | OH | MEDICAID |