Provider Demographics
NPI:1023056744
Name:MERCY PHYSICIAN NETWORK
Entity type:Organization
Organization Name:MERCY PHYSICIAN NETWORK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSHO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-398-0642
Mailing Address - Street 1:PO BOX 1848
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49443-1848
Mailing Address - Country:US
Mailing Address - Phone:231-672-2120
Mailing Address - Fax:231-728-5981
Practice Address - Street 1:2006 HOLTON RD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445
Practice Address - Country:US
Practice Address - Phone:231-672-3333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY HEALTH PARTNERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-03
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207R00000X, 207RG0300X, 363A00000X, 363L00000X, 207Q00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N28430OtherMEDICARE GROUP PTAN
MI0N33870OtherMEDICARE GROUP PTAN
MI0N33890OtherMEDICARE GROUP PTAN