Provider Demographics
NPI:1699591388
Name:MERCURY NEWCO INC
Entity type:Organization
Organization Name:MERCURY NEWCO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, BUSINESS OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-498-3972
Mailing Address - Street 1:584 MARKET ST STE 17462
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94104
Mailing Address - Country:US
Mailing Address - Phone:443-498-3972
Mailing Address - Fax:
Practice Address - Street 1:301 COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02121-3409
Practice Address - Country:US
Practice Address - Phone:443-498-3972
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-26
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health