Provider Demographics
NPI:1093998338
Name:MERCY PROFESSIONAL SERVICES
Entity Type:Organization
Organization Name:MERCY PROFESSIONAL SERVICES
Other - Org Name:FRAN A REPKA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:BURROUGHS
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:513-221-2330
Mailing Address - Street 1:2330 VICTORY PKWY
Mailing Address - Street 2:SUITE 500
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-2839
Mailing Address - Country:US
Mailing Address - Phone:513-221-2330
Mailing Address - Fax:513-221-8954
Practice Address - Street 1:2330 VICTORY PKWY
Practice Address - Street 2:SUITE 500
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45206-2839
Practice Address - Country:US
Practice Address - Phone:513-221-2330
Practice Address - Fax:513-221-8954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4022103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2923411Medicaid
OH2923411Medicaid