Basic Information
| Provider Information | |||||||||
| NPI: | 1912045774 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY MEDICAL GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 44428 WOODWARD AVE | ||||||||
| Address2: | LOWER LEVEL | ||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483415009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488586144 | ||||||||
| FaxNumber: | 2488586232 | ||||||||
| Practice Location | |||||||||
| Address1: | 1812 S ROCHESTER RD | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483073532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486563515 | ||||||||
| FaxNumber: | 2486567748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WEINER | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2488583140 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.