Healthcare Provider Details

I. General information

NPI: 1912951468
Provider Name (Legal Business Name): MERCY PROFESSIONAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 02/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E MICHIGAN AVE
GRAYLING MI
49738-1312
US

IV. Provider business mailing address

PO BOX 646
GRAYLING MI
49738-0646
US

V. Phone/Fax

Practice location:
  • Phone: 989-348-5461
  • Fax:
Mailing address:
  • Phone: 989-348-1040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE RIEMER-MATUZAK
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 989-348-5461