Provider Demographics
NPI:1740686450
Name:PORT HURON MERCY FAMILY CARE INC
Entity type:Organization
Organization Name:PORT HURON MERCY FAMILY CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:REBEKAH
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-985-1510
Mailing Address - Street 1:PO BOX 610669
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48061-0669
Mailing Address - Country:US
Mailing Address - Phone:810-985-1868
Mailing Address - Fax:810-966-3025
Practice Address - Street 1:2601 ELECTRIC AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6587
Practice Address - Country:US
Practice Address - Phone:810-985-1868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-06
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P08380Medicare Oscar/Certification