1063450708 NPI number — MERCY MEDICAL SERVICES

Table of content: (NPI 1063450708)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063450708 NPI number — MERCY MEDICAL SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERCY MEDICAL SERVICES
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:
WAKEFIELD MERCY MEDICAL CLINIC
Provider Other Organization Name Type Code:
3
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:
1063450708
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 328
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX CITY
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51102-0328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-279-5830
Provider Business Mailing Address Fax Number:
712-279-5883

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
308 ASH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAKEFIELD
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68784-5023
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-287-2267
Provider Business Practice Location Address Fax Number:
402-287-2267
Provider Enumeration Date:
06/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MONSMA
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE NETWORK DIRECTOR
Authorized Official Telephone Number:
712-279-2925

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363AM0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 100252199-00 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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