Basic Information
Provider Information | |||||||||
NPI: | 1215953856 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MERCY CLINICS INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MERCYONE PLEASANTHILL FAM MED CLINIC/MERCYONE PLEASANTHILL UC CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1475 | ||||||||
Address2: |   | ||||||||
City: | DES MOINES | ||||||||
State: | IA | ||||||||
PostalCode: | 503051475 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5156432400 | ||||||||
FaxNumber: | 5156434766 | ||||||||
Practice Location | |||||||||
Address1: | 5900 E UNIVERSITY AVE | ||||||||
Address2: | SUITE 100 | ||||||||
City: | PLEASANT HILL | ||||||||
State: | IA | ||||||||
PostalCode: | 503278457 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5156432400 | ||||||||
FaxNumber: | 5156434766 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/15/2006 | ||||||||
LastUpdateDate: | 10/31/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LENHARDT | ||||||||
AuthorizedOfficialFirstName: | AMBER | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 5153586971 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/31/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center |   | 261QP2300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
ID | Type | State | Issuer | Description | 0041962 | 05 | IA |   | MEDICAID | CD3776 | 01 | IA | RAILROAD MEDICARE | OTHER |