Provider Demographics
NPI:1770734691
Name:MERCY HEALTH-MARCUM & WALLACE HOSPITAL LLC
Entity type:Organization
Organization Name:MERCY HEALTH-MARCUM & WALLACE HOSPITAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:TRENA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:STOCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-779-0148
Mailing Address - Street 1:PO BOX 636544
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6544
Mailing Address - Country:US
Mailing Address - Phone:606-723-2115
Mailing Address - Fax:606-723-2951
Practice Address - Street 1:60 MERCY CT
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:KY
Practice Address - Zip Code:40336-1331
Practice Address - Country:US
Practice Address - Phone:606-723-2115
Practice Address - Fax:606-723-2951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-09
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
KY208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
K219130Medicare Oscar/Certification