Provider Demographics
NPI:1093103731
Name:MERCY HEALTH PHYSICIANS CINCINNATI, LLC
Entity Type:Organization
Organization Name:MERCY HEALTH PHYSICIANS CINCINNATI, LLC
Other - Org Name:MERCY HEALTH CARDIOVASCULAR, THORACIC, VASCULAR AND ENDOVASCULAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PAYER CREDENTIALING
Authorized Official - Prefix:MS
Authorized Official - First Name:CASSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAVLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-981-4684
Mailing Address - Street 1:4030 SMITH RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45209-1957
Mailing Address - Country:US
Mailing Address - Phone:513-421-3494
Mailing Address - Fax:513-345-2606
Practice Address - Street 1:4030 SMITH RD
Practice Address - Street 2:SUITE 300
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45209-1957
Practice Address - Country:US
Practice Address - Phone:513-421-3494
Practice Address - Fax:513-345-2606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0270942Medicaid
OH0270942Medicaid