Basic Information
| Provider Information | |||||||||
| NPI: | 1952480519 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST MARGARET MERCY HEALTHCARE CENTERS, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAKE RIDGE MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1000 | ||||||||
| Address2: | |||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463110800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198642107 | ||||||||
| FaxNumber: | 2198642251 | ||||||||
| Practice Location | |||||||||
| Address1: | 1573 N CLINE AVE | ||||||||
| Address2: | |||||||||
| City: | GRIFFITH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463191567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193832311 | ||||||||
| FaxNumber: | 2198381521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 06/23/2008 | ||||||||
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| AuthorizedOfficialLastName: | GRYZBEK | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2199322300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0090000854 | 01 | IL | BCBS GROUP NUMBER | OTHER | 200159110C | 05 | IN | MEDICAID |