Basic Information
Provider Information | |||||||||
NPI: | 1215978929 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MERCY MEDICAL SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MERCY INTERNAL MEDICINE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 328 | ||||||||
Address2: |   | ||||||||
City: | SIOUX CITY | ||||||||
State: | IA | ||||||||
PostalCode: | 511020328 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7122795830 | ||||||||
FaxNumber: | 7122795883 | ||||||||
Practice Location | |||||||||
Address1: | 624 JONES ST | ||||||||
Address2: | SUITE 5400 | ||||||||
City: | SIOUX CITY | ||||||||
State: | IA | ||||||||
PostalCode: | 511011924 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7122792510 | ||||||||
FaxNumber: | 7122792519 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/10/2006 | ||||||||
LastUpdateDate: | 02/20/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FLANNERY-HUGHES | ||||||||
AuthorizedOfficialFirstName: | M. ELIZABETH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7122792018 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/20/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 07228 | 01 | IA | WELLMARK GROUP NUMBER | OTHER | 10025144300 | 05 | IA |   | MEDICAID |