Provider Demographics
NPI:1104097294
Name:MERCY MEDICAL CENTER
Entity type:Organization
Organization Name:MERCY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:REILLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-705-1353
Mailing Address - Street 1:P.O. BOX 798
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11571
Mailing Address - Country:US
Mailing Address - Phone:516-705-1353
Mailing Address - Fax:516-705-3575
Practice Address - Street 1:1000 N. VILLAGE AVENUE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11571
Practice Address - Country:US
Practice Address - Phone:516-705-1353
Practice Address - Fax:516-705-3575
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-17
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY178140207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02898020Medicaid