Basic Information
| Provider Information | |||||||||
| NPI: | 1083636815 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY CLINICS INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAMILY MEDICINE OF URBANDALE, MERCY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1475 | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503051475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5156434374 | ||||||||
| FaxNumber: | 5156432784 | ||||||||
| Practice Location | |||||||||
| Address1: | 4005 NW URBANDALE DRIVE | ||||||||
| Address2: | |||||||||
| City: | URBANDALE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503227914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5156439200 | ||||||||
| FaxNumber: | 5156439247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 08/19/2013 | ||||||||
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| AuthorizedOfficialLastName: | PHILLIPS | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5156437238 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | CD3776 | 01 | IA | RAILROAD MEDICARE | OTHER | 0262725 | 05 | IA | MEDICAID |