Basic Information
| Provider Information | |||||||||
| NPI: | 1982708566 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH IOWA MERCY CLINICS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MERCYONE MASON CITY PEDIATRIC & ADOLESCENT CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 621 S ILLINOIS AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | MASON CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 504010000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6414943041 | ||||||||
| FaxNumber: | 6414943059 | ||||||||
| Practice Location | |||||||||
| Address1: | 910 N EISENHOWER AVE | ||||||||
| Address2: | |||||||||
| City: | MASON CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 504011525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6414285437 | ||||||||
| FaxNumber: | 6414285800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 11/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | ZOOK | ||||||||
| AuthorizedOfficialFirstName: | DANETTE | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6414287989 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0199455 | 05 | IA | MEDICAID | 12116 | 01 | IA | WELLMARK | OTHER |