Basic Information
| Provider Information | |||||||||
| NPI: | 1720026461 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY MEDICAL SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WAYNE MERCY MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 328 | ||||||||
| Address2: | |||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511020328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122795830 | ||||||||
| FaxNumber: | 7122795883 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 E 14TH ST | ||||||||
| Address2: | |||||||||
| City: | WAYNE | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687871152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023752500 | ||||||||
| FaxNumber: | 4023752463 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 09/27/2007 | ||||||||
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| AuthorizedOfficialLastName: | MONSMA | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE NETWORK DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7122792925 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363AM0700X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 0715037 | 05 | NE | MEDICAID | 100252197-00 | 05 | NE | MEDICAID |