Basic Information
Provider Information | |||||||||
NPI: | 1871667378 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MERCY MEDICAL CENTER, DBA MERCY HEALTH PARTNERS SPECIALTY GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
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: | 11/17/2006 | ||||||||
LastUpdateDate: | 02/12/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MONSON | ||||||||
AuthorizedOfficialFirstName: | KERRY | ||||||||
AuthorizedOfficialMiddleName: | S. | ||||||||
AuthorizedOfficialTitleorPosition: | VP FINANCE AND CFO | ||||||||
AuthorizedOfficialTelephone: | 7017747408 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 3888 | ND | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 208600000X | 10618 | ND | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   | 207X00000X | 3132 | ND | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 12754 | 05 | ND |   | MEDICAID | 711005 | 01 | ND | BCBS OF ND | OTHER |