Basic Information
| Provider Information | |||||||||
| NPI: | 1801928593 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERCY MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 15TH AVE W | ||||||||
| Address2: | |||||||||
| City: | WILLISTON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 588013821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017747401 | ||||||||
| FaxNumber: | 7017747479 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 15TH AVE W | ||||||||
| Address2: | |||||||||
| City: | WILLISTON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 588013821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017747401 | ||||||||
| FaxNumber: | 7017747479 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 06/23/2008 | ||||||||
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| AuthorizedOfficialLastName: | MONSON | ||||||||
| AuthorizedOfficialFirstName: | KERRY | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE CFO | ||||||||
| AuthorizedOfficialTelephone: | 7017747401 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 5052A | ND | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 1041C0700X | 5052A | ND | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 2084P0800X | 5052A | ND | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 11684 | 05 | ND | MEDICAID | 711002 | 01 | ND | BLUE SHIELD OF ND | OTHER |