Provider Demographics
NPI:1487643821
Name:MERCY HEALTH-MARCUM & WALLACE HOSPITAL LLC
Entity Type:Organization
Organization Name:MERCY HEALTH-MARCUM & WALLACE HOSPITAL LLC
Other - Org Name:MERCY HEALTH MARCUM AND WALLACE HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:TRENA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:STOCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-779-0148
Mailing Address - Street 1:PO BOX 636544
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6544
Mailing Address - Country:US
Mailing Address - Phone:270-444-2163
Mailing Address - Fax:270-444-2460
Practice Address - Street 1:60 MERCY CT
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:KY
Practice Address - Zip Code:40336-1331
Practice Address - Country:US
Practice Address - Phone:270-444-2163
Practice Address - Fax:270-444-2460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY01002526252Y00000X
282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY01002526Medicaid
KY01002526Medicaid