=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942354873
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MERCY MEMORIAL HOSPITAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2007
-----------------------------------------------------
Last Update Date | 04/28/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 STEWART RD STE 105
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48162-5304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-240-1770
-----------------------------------------------------
Fax | 734-240-1780
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 718 N MACOMB ST
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48162
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-240-8400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MENTAL HEALTH SERVICES DIRECTOR
-----------------------------------------------------
Name | LARRY CSOKASY
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 734-240-1770
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 580030
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------