1750715587 NPI number — MERCY HEALTH PHYSICIANS CINCINNATI LLC

Table of content: (NPI 1750715587)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750715587 NPI number — MERCY HEALTH PHYSICIANS CINCINNATI LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERCY HEALTH PHYSICIANS CINCINNATI LLC
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:
6
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:
1750715587
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1701 MERCY HEALTH PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45237-6147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4440 GLEN ESTE WITHAMSVILLE RD
Provider Second Line Business Practice Location Address:
STE 500
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45245-1318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-753-7488
Provider Business Practice Location Address Fax Number:
513-753-7879
Provider Enumeration Date:
08/28/2013

Additional Information

Authorized Official

Authorized Official Last Name:
FRIES
Authorized Official First Name:
ERIN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
CMO, MEDICAL GROUP
Authorized Official Telephone Number:
513-952-5045

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0270942 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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