Provider Demographics
NPI:1053582197
Name:MERCY PHYSICIAN GROUP, INC.
Entity type:Organization
Organization Name:MERCY PHYSICIAN GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:C
Authorized Official - Last Name:MCCLURE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-463-5549
Mailing Address - Street 1:214 S MIDLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-2602
Mailing Address - Country:US
Mailing Address - Phone:208-465-6900
Mailing Address - Fax:208-465-6910
Practice Address - Street 1:214 S MIDLAND BLVD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-2602
Practice Address - Country:US
Practice Address - Phone:208-465-6900
Practice Address - Fax:208-465-6910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies