Provider Demographics
NPI:1710954102
Name:MORAN, MERCEDES DEL CARMEN (CNM)
Entity Type:Individual
Prefix:
First Name:MERCEDES
Middle Name:DEL CARMEN
Last Name:MORAN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:621 MEMORIAL DR
Practice Address - Street 2:STE 403
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1063
Practice Address - Country:US
Practice Address - Phone:574-647-1405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-03
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704237039261Q00000X, 367A00000X
IN71004286A363L00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN00000080642OtherBCBS BMG SOUTHEAST NEIGHBORHOOD CTR
IN000000815003OtherBCBS BMG CENTENNIAL NEIGHBORHOOD HEALTH CTR
IN236040264OtherMEDICARE PTAN
IN000000814990OtherBCBS BMG CENTRAL NEIGHBORHOOD HEALTH CTR
IN200530760Medicaid
IN178420007Medicare PIN