Provider Demographics
NPI:1114104346
Name:MERCY HEALTH-ST RITAS MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:MERCY HEALTH-ST RITAS MEDICAL CENTER LLC
Other - Org Name:DR. AMBALAVANAN M.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SYSTEM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:RALSTON
Authorized Official - Suffix:
Authorized Official - Credentials:N/A
Authorized Official - Phone:419-996-5119
Mailing Address - Street 1:PO BOX 73577
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0002
Mailing Address - Country:US
Mailing Address - Phone:419-996-5114
Mailing Address - Fax:
Practice Address - Street 1:770 W HIGH ST
Practice Address - Street 2:SUITE 480
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-3990
Practice Address - Country:US
Practice Address - Phone:419-227-9500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH 35090880207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G87099Medicare UPIN