MEDICARE: OUR LADY OF MERCY CLINIC LLC

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	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1083492284
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OUR LADY OF MERCY CLINIC LLC

Provider Business Mailing Address
First Line	:	2410 NORTHSIDE DR
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33761-2236
Country	:	US
Telephone Number	:	727-499-0351
Fax Number	:	727-223-0157

Provider Business Practice Location Address
First Line	:	9336 LITTLE RD
Second Line	:
City	:	NEW PORT RICHEY
State	:	FL
Zip	:	34654-3415
Country	:	US
Telephone Number	:	727-233-6430
Fax Number	:

Authorized Official
Title or Position	:	MD
Name	:	AMGAD N MARCUS
Credential	:
Telephone Number	:	727-233-6430

Provider Enumeration Date	:	09/19/2023
Last Update Date	:	03/12/2024

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