Basic Information
| Provider Information | |||||||||
| NPI: | 1891862868 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERCY HEALTH NETWORK OF THE SOUTHERN REGION, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MERCY HEALTH WILSON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4401 W MEMORIAL RD | ||||||||
| Address2: | SUITE #141, ATTENTION BECKY | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731341785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059365800 | ||||||||
| FaxNumber: | 4059365810 | ||||||||
| Practice Location | |||||||||
| Address1: | 1152 US HIGHWAY 70A | ||||||||
| Address2: | |||||||||
| City: | WILSON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734631482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5806682882 | ||||||||
| FaxNumber: | 5806682772 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | THOMPSON | ||||||||
| AuthorizedOfficialFirstName: | BOBBY | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 5802206611 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.