Provider Demographics
NPI:1104304260
Name:MERCY HEALTH PHYSICIANS YOUNGSTOWN LLC
Entity type:Organization
Organization Name:MERCY HEALTH PHYSICIANS YOUNGSTOWN LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGION CEO
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:E
Authorized Official - Last Name:KLINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-884-7010
Mailing Address - Street 1:1044 BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44504-1006
Mailing Address - Country:US
Mailing Address - Phone:330-884-7010
Mailing Address - Fax:
Practice Address - Street 1:107 ROYAL BIRKDALE DR STE A
Practice Address - Street 2:
Practice Address - City:COLUMBIANA
Practice Address - State:OH
Practice Address - Zip Code:44408
Practice Address - Country:US
Practice Address - Phone:330-482-9350
Practice Address - Fax:330-482-2336
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY HEALTH PHYSICIANS YOUNGSTOWN LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-01
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3136878Medicaid