Provider Demographics
NPI:1285743088
Name:MERCY PHYSICIAN GROUP INC
Entity type:Organization
Organization Name:MERCY PHYSICIAN GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MATUSKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-854-4400
Mailing Address - Street 1:3661 S MIAMI AVE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33133-4236
Mailing Address - Country:US
Mailing Address - Phone:305-285-1017
Mailing Address - Fax:866-652-4157
Practice Address - Street 1:3661 S MIAMI AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133-4236
Practice Address - Country:US
Practice Address - Phone:305-285-5090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93096207XX0005X
208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Not Answered208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8626Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER