Provider Demographics
NPI:1942993019
Name:MERCY HEALTH PATHWAY LLC
Entity type:Organization
Organization Name:MERCY HEALTH PATHWAY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OLATUNJI
Authorized Official - Middle Name:
Authorized Official - Last Name:IBERU-OLUSHOGA
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:301-728-0345
Mailing Address - Street 1:1509 FITZPATRICK DR
Mailing Address - Street 2:
Mailing Address - City:SEVERN
Mailing Address - State:MD
Mailing Address - Zip Code:21144-3142
Mailing Address - Country:US
Mailing Address - Phone:301-728-0345
Mailing Address - Fax:
Practice Address - Street 1:1509 FITZPATRICK DR
Practice Address - Street 2:
Practice Address - City:SEVERN
Practice Address - State:MD
Practice Address - Zip Code:21144-3142
Practice Address - Country:US
Practice Address - Phone:301-728-0345
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center