Provider Demographics
NPI:1841220514
Name:MERCY HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:MERCY HEALTH SERVICES, INC.
Other - Org Name:EASTOVER INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:WIENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-355-0648
Mailing Address - Street 1:5000 AIRPORT CENTER PKWY STE A
Mailing Address - Street 2:ATTN: SHANNA
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-5899
Mailing Address - Country:US
Mailing Address - Phone:704-512-4116
Mailing Address - Fax:704-371-7284
Practice Address - Street 1:2608 E 7TH ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-4375
Practice Address - Country:US
Practice Address - Phone:704-344-9034
Practice Address - Fax:704-344-9544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8902682Medicaid
NC8902682Medicaid