MEDICARE: ST MARGARET MERCY HEALTHCARE CENTERS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician
2	207R00000X	Internal Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0090000854	OTHER	IL	BCBS GROUP NUMBER

General Provider Information

NPI Number	:	1801975438
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST MARGARET MERCY HEALTHCARE CENTERS, INC.

Provider Business Mailing Address
First Line	:	PO BOX 1000
Second Line	:
City	:	DYER
State	:	IN
Zip	:	46311-0800
Country	:	US
Telephone Number	:	219-864-2107
Fax Number	:	219-864-2251

Provider Business Practice Location Address
First Line	:	2001 E COLUMBUS DR
Second Line	:	SUITE # C
City	:	EAST CHICAGO
State	:	IN
Zip	:	46312-2829
Country	:	US
Telephone Number	:	219-933-2623
Fax Number	:	219-378-9283

Authorized Official
Title or Position	:	PRESIDENT
Name	:	THOMAS GRYZBEK
Credential	:
Telephone Number	:	219-932-2300

Provider Enumeration Date	:	11/03/2006
Last Update Date	:	06/23/2008

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