Provider Demographics
NPI:1598015208
Name:MERCURY MEDICAL
Entity Type:Organization
Organization Name:MERCURY MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:SEWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-690-1835
Mailing Address - Street 1:171 GROVE PL
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-6438
Mailing Address - Country:US
Mailing Address - Phone:616-690-1835
Mailing Address - Fax:
Practice Address - Street 1:171 GROVE PL
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-6438
Practice Address - Country:US
Practice Address - Phone:616-690-1835
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-11
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0071631041C0700X
CT0459782084N0400X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty