Provider Demographics
NPI:1659558765
Name:MERCY MEMORIAL HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:MERCY MEMORIAL HOSPITAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GROUP REP
Authorized Official - Prefix:
Authorized Official - First Name:KIANOUSH
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAGHNAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-240-1442
Mailing Address - Street 1:718 N MACOMB ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-7815
Mailing Address - Country:US
Mailing Address - Phone:734-240-1440
Mailing Address - Fax:734-240-1550
Practice Address - Street 1:718 N MACOMB ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-7815
Practice Address - Country:US
Practice Address - Phone:734-240-1440
Practice Address - Fax:734-240-1550
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY MEMORIAL OB SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E81076OtherBLUE CROSS