Basic Information
| Provider Information | |||||||||
| NPI: | 1104972983 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERCY PHYSICIAN GROUP INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1512 12TH AVE RD | ||||||||
| Address2: | |||||||||
| City: | NAMPA | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836866008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084635000 | ||||||||
| FaxNumber: | 2084635578 | ||||||||
| Practice Location | |||||||||
| Address1: | 1512 12TH AVE RD | ||||||||
| Address2: | |||||||||
| City: | NAMPA | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836866008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084635000 | ||||||||
| FaxNumber: | 2084635578 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 04/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | CHECKETTS | ||||||||
| AuthorizedOfficialFirstName: | B | ||||||||
| AuthorizedOfficialMiddleName: | LANNIE | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2084635531 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CFO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207QA0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adolescent Medicine | 207QG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207QS0010X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 207QA0505X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
No ID Information.