Provider Demographics
NPI:1972682581
Name:ST MARGARET MERCY HEALTHCARE CENTERS
Entity Type:Organization
Organization Name:ST MARGARET MERCY HEALTHCARE CENTERS
Other - Org Name:DYER FAMILY PRACTICE
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 1:840 RICHARD RD
Practice Address - Street 2:SUITE 3
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-1993
Practice Address - Country:US
Practice Address - Phone:219-322-1450
Practice Address - Fax:219-322-8260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0090000854OtherBCBS GROUP NUMBER
IN200159110AMedicaid
IN140230Medicare ID - Type UnspecifiedGROUP ID
IN200159110AMedicaid