Basic Information
Provider Information | |||||||||
NPI: | 1053346320 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MERCY HOSPITAL LEBANON | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MERCY HOSPITAL LEBANON | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 HOSPITAL DR | ||||||||
Address2: |   | ||||||||
City: | LEBANON | ||||||||
State: | MO | ||||||||
PostalCode: | 655369210 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4175336100 | ||||||||
FaxNumber: | 4175336173 | ||||||||
Practice Location | |||||||||
Address1: | 100 HOSPITAL DR | ||||||||
Address2: |   | ||||||||
City: | LEBANON | ||||||||
State: | MO | ||||||||
PostalCode: | 65536 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4175336100 | ||||||||
FaxNumber: | 4175336173 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2006 | ||||||||
LastUpdateDate: | 02/16/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROBERTS | ||||||||
AuthorizedOfficialFirstName: | WILLIAM | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
AuthorizedOfficialTelephone: | 4178207363 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MERCY HOSPITAL LEBANON | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/16/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 450-6 | MO | Y |   | Hospital Units | Medicare Defined Swing Bed Unit |   |
No ID Information.