MEDICARE: MERCURY NEWCO INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	261QM0850X	Adult Mental Health Clinic/Center
2	261QM0855X	Adolescent and Children Mental Health Clinic/Center
3	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1699591388
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERCURY NEWCO INC

Provider Business Mailing Address
First Line	:	584 MARKET ST STE 17462
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94104
Country	:	US
Telephone Number	:	443-498-3972
Fax Number	:

Provider Business Practice Location Address
First Line	:	301 COLUMBIA RD
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02121-3409
Country	:	US
Telephone Number	:	443-498-3972
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR, BUSINESS OPERATIONS
Name	:	MICHAEL DAI
Credential	:
Telephone Number	:	443-498-3972

Provider Enumeration Date	:	11/26/2024
Last Update Date	:	11/26/2024

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