MEDICARE: MERCY HEALTH PARTNERS

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	104100000X	Social Worker	AB033570	MI
2	207Q00000X	Family Medicine Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	CH3289	OTHER	MI	RAIL ROAD MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	0F40011	OTHER	MI	BCBSMI
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	0F40012	OTHER	MI	BCBSM
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	16106	OTHER	MI	BCBS FACILITY CODE

General Provider Information

NPI Number	:	1972734200
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERCY HEALTH PARTNERS

Provider Business Mailing Address
First Line	:	611 E MAIN ST
Second Line	:
City	:	HART
State	:	MI
Zip	:	49420-1190
Country	:	US
Telephone Number	:	231-873-5675
Fax Number	:	231-873-1825

Provider Business Practice Location Address
First Line	:	611 E MAIN ST
Second Line	:
City	:	HART
State	:	MI
Zip	:	49420-1190
Country	:	US
Telephone Number	:	231-873-5675
Fax Number	:	231-873-1825

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	BETTY ELLER
Credential	:
Telephone Number	:	231-672-2120

Provider Enumeration Date	:	08/04/2009
Last Update Date	:	02/24/2020

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1962434043 — PAUL A WAGNER DO
Practice Location Address:

611 EAST MAIN ST
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1922030063 — RONALD E GRAESER DO
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1093816316 — DR. MIKE KOZMINSKI M.D.
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Directions to “MERCY HEALTH PARTNERS ” Practice Location

Language	Start Address	Practice Location

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