Basic Information
Provider Information
NPI: 1588773634
EntityType: 2
ReplacementNPI:  
OrganizationName: MERCY MEDICAL CENTER
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
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OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1301 15TH AVE W
Address2:  
City: WILLISTON
State: ND
PostalCode: 588013821
CountryCode: US
TelephoneNumber: 7017747470
FaxNumber: 7017747479
Practice Location
Address1: 1301 15TH AVE W
Address2:  
City: WILLISTON
State: ND
PostalCode: 588013821
CountryCode: US
TelephoneNumber: 7017747470
FaxNumber: 7017747479
Other Information
ProviderEnumerationDate: 08/30/2006
LastUpdateDate: 08/22/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: MONSON
AuthorizedOfficialFirstName: KERRY
AuthorizedOfficialMiddleName: S.
AuthorizedOfficialTitleorPosition: VP FINANCE/CFO
AuthorizedOfficialTelephone: 7017747470
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MS.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
3336I0012X5052ANDY SuppliersPharmacyInstitutional Pharmacy

ID Information
IDTypeStateIssuerDescription
212178305MT MEDICAID
2079005ND MEDICAID


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