Basic Information
| Provider Information | |||||||||
| NPI: | 1447284898 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY HOSPITAL LEBANON | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MERCY HOSPITAL LEBANON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 655369210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4175336100 | ||||||||
| FaxNumber: | 4175336173 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4175336100 | ||||||||
| FaxNumber: | 4175336173 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 02/16/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROBERTS | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 4178207363 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 450-6 | MO | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 540492006 | 05 | MO | MEDICAID | 010492007 | 05 | MO | MEDICAID | 114678 | 01 | MO | HEALTHLINK COMMERCIAL | OTHER |