=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528234713
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MERCY HOSPITAL & MEDICAL CENTER ROCKS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2008
-----------------------------------------------------
Last Update Date | 05/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2525 S MICHIGAN AVE B-522
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60616-2333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-567-6691
-----------------------------------------------------
Fax | 312-567-6156
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2525 S MICHIGAN AVE B-522
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60616-2333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-567-6691
-----------------------------------------------------
Fax | 312-567-6156
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP FINANCE CFO
-----------------------------------------------------
Name | THOMAS J GARVEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 312-567-2000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 2170152008
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------