Provider Demographics
NPI:1114113222
Name:MERCURY CENTER PA
Entity Type:Organization
Organization Name:MERCURY CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:OLDRICH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:561-967-6800
Mailing Address - Street 1:7775 LAKE WORTH RD
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-2536
Mailing Address - Country:US
Mailing Address - Phone:561-967-6800
Mailing Address - Fax:561-967-0975
Practice Address - Street 1:7775 LAKE WORTH RD
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-2536
Practice Address - Country:US
Practice Address - Phone:561-967-6800
Practice Address - Fax:561-967-0975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-21
Last Update Date:2008-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2584213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5113920001Medicare NSC