=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598713638
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY MERCY HEALTH PARTNERS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2006
-----------------------------------------------------
Last Update Date | 06/07/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 W MCCREIGHT AVE SUITE 209
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45504-1842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-399-6922
-----------------------------------------------------
Fax | 937-399-2270
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 W MCCREIGHT AVE SUITE 209
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45504-1842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-399-6922
-----------------------------------------------------
Fax | 937-399-2270
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. MARK WIENER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 937-328-9515
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | N/A
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------