Basic Information
| Provider Information | |||||||||
| NPI: | 1568474369 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY MEDICAL CENTER - NEW HAMPTON | ||||||||
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| OtherOrganizationName: | MERCY FAMILY CLINIC - NEW HAMPTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 1ST ST NW STE 101 | ||||||||
| Address2: | |||||||||
| City: | MASON CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 504012932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 6414943059 | ||||||||
| Practice Location | |||||||||
| Address1: | 308 N MAPLE AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAMPTON | ||||||||
| State: | IA | ||||||||
| PostalCode: | 506591142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6413942151 | ||||||||
| FaxNumber: | 6413941999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 08/29/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TRAMMEL | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 6414287984 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Emergency Medical Service Providers | Emergency Medical Technician, Paramedic | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 09398 | 01 | IA | WELLMARK | OTHER | 0208504 | 05 | IA | MEDICAID |