Provider Demographics
NPI:1922248772
Name:MERCY HEALTH PARTNERS - PHYSICIAN SPECIALIST
Entity Type:Organization
Organization Name:MERCY HEALTH PARTNERS - PHYSICIAN SPECIALIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-672-2120
Mailing Address - Street 1:PO BOX 776982
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6982
Mailing Address - Country:US
Mailing Address - Phone:800-494-5797
Mailing Address - Fax:
Practice Address - Street 1:1675 LEAHY ST STE 324B
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-5500
Practice Address - Country:US
Practice Address - Phone:231-672-8700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY HEALTH PARTNERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-05
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 207RG0100X, 207RI0200X, 363A00000X, 363L00000X, 363LF0000X
MI207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700F10016OtherBCBS
MIMI1763OtherMEDICARE PTAN
MI500F10015OtherBCBS MID-LEVELS