Provider Demographics
NPI:1689746000
Name:ST MARGARET MERCY HEALTHCARE CENTERS, INC.
Entity Type:Organization
Organization Name:ST MARGARET MERCY HEALTHCARE CENTERS, INC.
Other - Org Name:LAKE RIDGE OCCUPATIONAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:GRYZBEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-932-2300
Mailing Address - Street 1:PO BOX 1000
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-0800
Mailing Address - Country:US
Mailing Address - Phone:219-864-2107
Mailing Address - Fax:219-864-2251
Practice Address - Street 1:1573 N CLINE AVE
Practice Address - Street 2:
Practice Address - City:GRIFFITH
Practice Address - State:IN
Practice Address - Zip Code:46319-1567
Practice Address - Country:US
Practice Address - Phone:219-838-2312
Practice Address - Fax:219-838-1521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0090000854OtherBCBS GROUP NUMBER
IN140220Medicare PIN
IL0090000854OtherBCBS GROUP NUMBER