Basic Information
| Provider Information | |||||||||
| NPI: | 1558478016 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY KANSAS COMMUNITIES INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MERCY HOSPITAL-FORT SCOTT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 WOODLAND HILLS BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT SCOTT | ||||||||
| State: | KS | ||||||||
| PostalCode: | 667018797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202232200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 401 WOODLAND HILLS BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT SCOTT | ||||||||
| State: | KS | ||||||||
| PostalCode: | 667018797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202232200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 03/13/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HUNTER | ||||||||
| AuthorizedOfficialFirstName: | SHELLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4176252459 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MERCY KANSAS COMMUNITIES INC | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | H-006-001 | KS | N | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 261QE0002X | H-006-001 | KS | Y | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care |
ID Information
| ID | Type | State | Issuer | Description | 100089300C | 05 | KS | MEDICAID | 014036 | 01 | KS | BLUE CROSS, PC | OTHER |