1164613261 NPI number — ANN S MERCER MD PA

Table of content: (NPI 1164613261)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164613261 NPI number — ANN S MERCER MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANN S MERCER MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164613261
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2801 MISSOURI AVE STE 12
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS CRUCES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88011-5061
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-522-6900
Provider Business Mailing Address Fax Number:
505-522-8891

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2801 MISSOURI AVE STE 12
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS CRUCES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88011-5061
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-522-6900
Provider Business Practice Location Address Fax Number:
505-522-8891
Provider Enumeration Date:
08/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MERCER
Authorized Official First Name:
ANN
Authorized Official Middle Name:
SHUKRI
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
505-522-6900

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  84-79 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 33407 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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