Provider Demographics
NPI:1023362100
Name:CLEVELAND CLINIC MERCY HOSPITAL
Entity Type:Organization
Organization Name:CLEVELAND CLINIC MERCY HOSPITAL
Other - Org Name:ST. PAUL DENTAL SERVICE
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-489-1268
Mailing Address - Street 1:1459 SUPERIOR AVE NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44705-1964
Mailing Address - Country:US
Mailing Address - Phone:330-588-4893
Mailing Address - Fax:330-453-2793
Practice Address - Street 1:1459 SUPERIOR AVE NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44705-1964
Practice Address - Country:US
Practice Address - Phone:330-588-4893
Practice Address - Fax:330-453-2793
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY MEDICAL CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-29
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH360070Medicare Oscar/Certification