1043268451 NPI number — MERCY HOSPITAL WALDRON

Table of Contents

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:
Provider Other Organization Name Type Code:
6
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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