Basic Information
| Provider Information | |||||||||
| NPI: | 1245397736 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERCY MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | CHI ST ALEXIUS HEALTH WILLISTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 15TH AVE W | ||||||||
| Address2: | |||||||||
| City: | WILLISTON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 588013821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017747400 | ||||||||
| FaxNumber: | 7017747479 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 15TH AVE W | ||||||||
| Address2: | |||||||||
| City: | WILLISTON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 588013821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017747400 | ||||||||
| FaxNumber: | 7017747479 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 11/17/2016 | ||||||||
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| AuthorizedOfficialLastName: | RUARK | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP-OPERATIONAL FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 7017747400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 11444 | 05 | ND | MEDICAID | 02061001 | 01 | ND | BLUE CROSS OF NORTH DAKOT | OTHER |