Basic Information
| Provider Information | |||||||||
| NPI: | 1942245154 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERCY HEALTH-ST CHARLES HOSPITAL LLC | ||||||||
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| OtherOrganizationName: | BAY MEADOWS FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 JEFFERSON AVE | ||||||||
| Address2: | 4TH FL | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436241120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192518997 | ||||||||
| FaxNumber: | 4192513553 | ||||||||
| Practice Location | |||||||||
| Address1: | 2815 DUSTIN RD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | OREGON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436163495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198749998 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 01/13/2022 | ||||||||
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| AuthorizedOfficialLastName: | PLATZKE | ||||||||
| AuthorizedOfficialFirstName: | SAMANTHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4192512046 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
No ID Information.