Basic Information
| Provider Information | |||||||||
| NPI: | 1972781714 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERCY MEMORIAL HOSPITAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 718 N MACOMB ST | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481627815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342401770 | ||||||||
| FaxNumber: | 7342401550 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 STEWART RD | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481625304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342401770 | ||||||||
| FaxNumber: | 7342401550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2008 | ||||||||
| LastUpdateDate: | 08/31/2011 | ||||||||
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| AuthorizedOfficialLastName: | CSOKASY | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MENTAL HLTH SERVICES DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7342401770 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE FAMILY CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 580030 | MI | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 750910950 | 01 | MI | BLUE CROSS | OTHER |