Basic Information
| Provider Information | |||||||||
| NPI: | 1699728550 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY HEALTH SYSTEM CORPORATION | ||||||||
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| OtherOrganizationName: | MERCY WALWORTH HOSPITAL AND MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | N2950 STATE ROAD 67 | ||||||||
| Address2: | |||||||||
| City: | LAKE GENEVA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531472655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622450535 | ||||||||
| FaxNumber: | 2622452198 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 07/23/2020 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 6087566000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MERCY HEALTH CORPORATION | ||||||||
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| NPICertificationDate: | 07/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 310-800 | WI | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 261QP2000X | 3108-800 | WI | N | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | 332B00000X | 310800 | WI | N | Suppliers | Durable Medical Equipment & Medical Supplies | 282NC0060X | 1062 | WI | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 11024910 | 05 | WI | MEDICAID |