Basic Information
| Provider Information | |||||||||
| NPI: | 1043268451 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY HOSPITAL WALDRON | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MERCY FAMILY MEDICINE - WALDRON | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5401 ELLSWORTH RD | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729033219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4793141101 | ||||||||
| FaxNumber: | 4793144704 | ||||||||
| Practice Location | |||||||||
| Address1: | 1341 W 6TH ST | ||||||||
| Address2: | |||||||||
| City: | WALDRON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729587642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4796372136 | ||||||||
| FaxNumber: | 4796375411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 02/17/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CLOUSE DAY | ||||||||
| AuthorizedOfficialFirstName: | SHERRY | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE MERCY CAH | ||||||||
| AuthorizedOfficialTelephone: | 4178208439 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 100698850C | 05 | OK | MEDICAID | 5B332 | 01 | AR | BLUECROSS BLUESHIELD | OTHER | 146846729 | 05 | AR | MEDICAID |