Provider Demographics
NPI:1972734200
Name:MERCY HEALTH PARTNERS
Entity type:Organization
Organization Name:MERCY HEALTH PARTNERS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-672-2120
Mailing Address - Street 1:611 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HART
Mailing Address - State:MI
Mailing Address - Zip Code:49420-1190
Mailing Address - Country:US
Mailing Address - Phone:231-873-5675
Mailing Address - Fax:231-873-1825
Practice Address - Street 1:611 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HART
Practice Address - State:MI
Practice Address - Zip Code:49420-1190
Practice Address - Country:US
Practice Address - Phone:231-873-5675
Practice Address - Fax:231-873-1825
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY HEALTH PARTNERS-LAKESHORE CAMPUS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-08-04
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAB033570104100000X
207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI112963232Medicaid
MICH3289OtherRAIL ROAD MEDICARE PTAN
MI113015197Medicaid
MI0F40011OtherBCBSMI
MI112963241Medicaid
MI0F40012OtherBCBSM
MI113269528Medicaid
MI16106OtherBCBS FACILITY CODE
MI113015197Medicaid
MI23-8627Medicare PIN
MICH3289OtherRAIL ROAD MEDICARE PTAN
MIR38852Medicare UPIN
MI112963241Medicaid
MIM17481Medicare Oscar/Certification
MI0F40011OtherBCBSMI