1043268451 NPI number — MERCY HOSPITAL WALDRON

Table of content: (NPI 1043268451)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043268451 NPI number — MERCY HOSPITAL WALDRON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERCY HOSPITAL WALDRON
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MERCY FAMILY MEDICINE - WALDRON
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043268451
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5401 ELLSWORTH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT SMITH
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72903-3219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-314-1101
Provider Business Mailing Address Fax Number:
479-314-4704

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1341 W 6TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALDRON
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72958-7642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-637-2136
Provider Business Practice Location Address Fax Number:
479-637-5411
Provider Enumeration Date:
05/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CLOUSE DAY
Authorized Official First Name:
SHERRY
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
VP FINANCE MERCY CAH
Authorized Official Telephone Number:
417-820-8439

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100698850C , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5B332 . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 146846729 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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