Basic Information
| Provider Information | |||||||||
| NPI: | 1366039067 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY HEALTH SYSTEM CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 MINERAL POINT AVE | ||||||||
| Address2: | |||||||||
| City: | JANESVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535482940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087566000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 507 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WHITEWATER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531901852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2624730400 | ||||||||
| FaxNumber: | 2624730408 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2020 | ||||||||
| LastUpdateDate: | 12/29/2020 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP CFO | ||||||||
| AuthorizedOfficialTelephone: | 8159716752 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MERCY HEALTH CORPORATION | ||||||||
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| NPICertificationDate: | 12/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.