Basic Information
Provider Information | |||||||||
NPI: | 1912247818 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MERCY CLINICS, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MERCY PEDIATRIC INTENSIVISTS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1475 | ||||||||
Address2: |   | ||||||||
City: | DES MOINES | ||||||||
State: | IA | ||||||||
PostalCode: | 503051475 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5156438677 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1111 6TH AVE | ||||||||
Address2: | MAIN 3 | ||||||||
City: | DES MOINES | ||||||||
State: | IA | ||||||||
PostalCode: | 503142613 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5156438677 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/01/2013 | ||||||||
LastUpdateDate: | 01/31/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PHILLIPS | ||||||||
AuthorizedOfficialFirstName: | SHARON | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP PRIMARY CARE DIVISION | ||||||||
AuthorizedOfficialTelephone: | 5156433270 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0203X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
No ID Information.