Provider Demographics
NPI:1710109962
Name:MERCY CLINIC, INC
Entity Type:Organization
Organization Name:MERCY CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:REXFORD
Authorized Official - Middle Name:YAO
Authorized Official - Last Name:AGBENOHEVI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-372-8668
Mailing Address - Street 1:315 N WASHINGTON AVE
Mailing Address - Street 2:SUITE 109
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-2603
Mailing Address - Country:US
Mailing Address - Phone:931-372-8668
Mailing Address - Fax:
Practice Address - Street 1:315 N WASHINGTON AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2603
Practice Address - Country:US
Practice Address - Phone:931-372-8668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34431207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4114708OtherBLUE CROSS BLUE SHIELD
TN3855768Medicaid
TN3855768Medicaid
TN4114708OtherBLUE CROSS BLUE SHIELD
TN3733024Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
TNH19178Medicare UPIN